ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the...

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ENDOMETRIOSIS Akmal Abbasi

Transcript of ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the...

Page 1: ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the uterine cavity.

ENDOMETRIOSIS

Akmal Abbasi

Page 2: ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the uterine cavity.

DEFINITION

•The presence of functional endometrial tissue outside the uterine cavity.

Page 3: ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the uterine cavity.

EPIDEMIOLOGYAffects 5-20% of all women of

childbearing age.

Mean age of diagnosis 25-29yrs

No racial difference in prevalence.

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Sites

• Pelvic• Extra pelvic• Umbilicus.• Scars (Lap.).• Lungs & plura.• Others.

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Pelvic Endometriosis

• Uterine= Adenomyosis (50%).• Extraut:- Ovary 30%- Pelvic peritoneum 10%.- F. tube.- Vagina.-Bladder & rectum.- Pelvic colon.- Ligaments.

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ETIOLOGY

•Three main theories of pathogenesis

•Retrograde transport of endometrial tissue through the fallopian tubes at menstruation leading to seed of the peritoneal cavity.

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ETIOLOGY

•Metaplastic transformation of coelomic epithelium leading to functioning endometrial tissue extra pelvic sites.

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ETIOLOGY

• Spread of endometrial tissue through lymphatic and vascular channels.

• Possibility of autoimmune cause.

• Possible role of toxic chemical exposure.

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SYMPTOMSDysmenorrhea.

Dyspareunia.

Infertility.

Menstrual irregularities.

Chronic pelvic pain.

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Age at Diagnosis< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%

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CLINICAL FINDINGSNormal Physical exam even with

moderate to severe endometriosis.

Fixed retroversion of uterus.

Rectovaginal exam

•Uteroscral or rectovaginal septum nodularity

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CLINICAL FINDINGS

Pelvic exam (premenstrual )

•Fixed uterine retroversion.

•CMT.

•Adenexal tenderness.

•Adenexal masses- endometrioma (Chocolate cyst) of the ovary- (15cm)

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DIFFERENTIAL DIAGNOSIS

Chronic PID.Pelvic adhesions from PIDPrior surgery.Ovarian cysts.Ovarian tumors.

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LAB EVALUATION

CA 125•Found repeatedly in patients.

•Not recommended for screening.GC and chlamydia.CBCUrinalysis.

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DIAGNOSTIC EVALUTIOAN

Ultrasound

• Identification of cysts.

•Cannot detect focal implants.

MRI

•Sensitivity and specificity very low.

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DIAGNOSTIC EVALUTIOAN

Visualization by Laparoscopy or laparotomy considered the gold standard of for diagnosis.

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Treatment: Overall Approach• Recognize Goals:

– Pain Management

– Preservation / Restoration of Fertility

• Discuss with Patient:

– Disease may be Chronic and Not Curable

– Optimal Treatment Unproven or Nonexistent

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Classification / Staging

• Several Proposed Schemes

• Revised AFS System: Most Often Used

• Ranges from Stage I (Minimal) to Stage IV (Severe)

• Staging Involves Location and Depth of Disease, Extent of Adhesions

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TREATMENT

Optimal treatment regimen depends on

Desired pain relief.

Desired fertility.

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TREATMENTSurgeryConservativePreserve reproductive organs

Use of laser or thermal cautery.

Adhesiolysis via laporoscopy or laparatomy.

1/3 of patients have a recurrence.

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TREATMENTSurgeryRadical (definitive procedure)

•Hysterectomy with salpingo-oophorectomy.

•90% of patients pain free.

•Not for women desiring pregnancy.

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TREATMENT

Drugs of choiceDanazol (Danocrine).GnRH agonistsProgesterons

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TREATMENTDanazol (Danocrine).Derivative of 17-ethinyl testosterone.

400mg – 800mg b.i.d to q.I.d.

Creates high androgen ,low estrogen state with anovulation and amenorrhea , inhibits the the growth of endometrial tissue.

6mths or 2wks if as adjunct therapy.

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TREATMENTGnRH agonists (creates hypoestrogenic state) Usually 6mth duration of treatment)

Nafarelin acetate (Synarel)• 0.2 – 0.4mg intranasally b.i.d.

Leuprolide acetate ( Luprom)• 3.75mg IM monthly (depot).

• 0.5 – 1.0mg SQ daily.

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TREATMENTProgesterons (causes atrophy of endometium)

Depo-Provera• 100mg q2wks PO for 4 doses.

• Then 200mg monthly for 4 mths.

Medroxyprogesterone acetate (MPA)• 30mg PO Daily for 3 mths.

• Depot may cause prolonged anovulation.

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TREATMENT

ALTERNATIVE DRUGSCombined estrogen –progesterone

•OCs with 30 to 35g ethinyl estradiol to produce amenorrhea.

•Less effective than other meds.

•Use if other drugs are contraindicated.

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TREATMENTNSAIDs may be effective for pain relief

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Patient educationAvoid delaying

childbirth once diagnnosis is made.