Transcript Endometriosis

Endometriosis
Max Brinsmead MB BS PhD
May 2015
Historical Perspective
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1970’s
“A disease of uncertain aetiology whose relevance to
fertility is uncertain”
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1980’s
“A common condition that may be present in as many as
one woman in four”
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1990’s
Much more known about aetiology. Principles of
management emerging.
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2000+
 Evidence-based management
Endometriosis is:
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Ectopic endometrium i.e. “internal menstruation”
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Requires laparoscopy +/- biopsy for diagnosis
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Activity is more important than appearance
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Symptoms do not always correlate with grading
Symptoms of Endometriosis
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The Classic Triad…
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Dysmenorrhoea
Dyspareunia
Infertility
Symptoms of Endometriosis
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But consider also…
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Pre menstrual staining
Pain with defaecation during menstruation
Intermenstrual pain
Disordered cycles
Family history
Diagnosis of Endometriosis
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A Careful History (The most important)
Rule out other Causes of Symptoms (The
next most important)
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Examination (not much help)
Ultrasound (of little value)
MRI (useful for rectovaginal deposits)
Laparoscopy (The gold standard)
Serum CA125 (Lacks sensitivity)
Iridology (a good guess!)
Differential Diagnosis:
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Primary Dysmenorrhoea
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Irritable Bowel Syndrome
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Ovulation Pain
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Pelvic Inflammatory Disease
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Psychosexual Problems
Aetiology
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Two Main Theories:
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Retrograde menstruation
Peritoneal metaplasia
Predisposing Factors
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Familial predisposition
Disordered immunity
Environmental toxins
Recurrent ovulation
Infertile partner
Obstructed menstrual flow
Principles of Management:
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When the Problem is Pain – Use Medical
Rx
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When the Problem is Infertility – Use
Surgical Rx
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When there is no Problem – Use no Rx
Medical Therapy Options
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Progestins
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COC (best in continuous form)
Provera or Norethisterone
The Mirena IUS
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Danazol & Gestrinone
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GnRH agonists +/- Add Back Therapy
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A question of side effects
Cochrane Conclusions
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Oral & rectal Chinese Herbal Medicine better
than Danazol in both pain reduction and
shrinkage of masses
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Auricular acupunture effective in pain relief
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Inconclusive evidence that NSAIDs are any
better than pacebo
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But side effects certainly can occur
Cochrane Conclusions(2)
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COC as effective as GnRHa in control of
dysmenorrhoea 6m after therapy but GNRHa
better in terms of dyspareunia
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Oral Provera 100 mg daily more effective than
placebo (but not Dyhydrogesterone). IM route
no better
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GnRHa are no more effective than Danazol and
side effects are more frequent
Cochrane Conclusions(3)
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Laparoscopy with diathermy is more effective
than just laparoscopy
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For up to 12m after for pain
For conception (OR 1.66, CI 1.09-2.51)
There is no advantage from pre operative
medical Rx but one small trial showed less pain
if a Mirena is provided after surgery (OR 0.14, CI
0.02-0.75)
There is a risk of symptom recurrence if HRT
with E2 is used after pelvic clearance
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