Endometriosis (Complete)

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ENDOMETRIOSISESHRE Guidelines on Endometriosis 2013Justin W. Ng Sinco

The following will be presented:Case PresentationEndometriosisDefinitionEpidemiologyEtiologyDiagnosisTreatment of SymptomsCase PresentationE.L., 30 year-old Gravida 1 Para 1 (1001) who came in with a chief complaint of hypogastric pain.E.L., 30 y.o.Gravida 1 Para 1 (1001)Born on July 28, 1984 in ManilaLiving in Camarin, CaloocanWorks as a Telecommunication specialistMarriedHistory of Present IllnessMenarche at 13 years oldSubsequent menses were regular28 32 days interval3 5 days durationModerate flow, 4 pads per day(+) DysmenorrheaHistory of Present Illness5 years PTCSevere cyclic hypogastric painWorsened after menstruationWeakness and easy fatigabilityNo heavy bleeding, fever, dysuria, cough, colds, headacheHistory of Present Illness5 years PTCConsult at private OBEndometriotic cyst, left ovaryPolycystic ovariesFolic Acid 5mg ODVitamin B complex ODOCP for 3 monthsHistory of Present Illness3 years PTCDanazol 200 mg 1 tab BID for 30 days (2012)Injectable DMPA injected every three months until November 2013

1 year PTCMenstruation resumed regular cycle (May 2014)

History of Present Illness

History of Present Illness5 days PTCTransvaginal UltrasoundAnteverted, normal-sized uterus with proliferative endometrium (0.6 cm)Right ovary is converted to a unilocular cyst with low to medium level echoes measuring 3.2x2.5x2cmLeft ovary is converted to a unilocular cyst with low to medium level echoes measuring 2.8x2.6x2cmCervix is unremarkableDx: G1P1 (1001); AUB secondary to Bilateral Endometriotic CystsPast Medical HistoryHad mumps during childhoodBronchial asthma: last attack 1995 1996Non-hypertensive, non-diabeticNo known allergies to food and drugsNo history of prior hospitalizationFamily HistoryFather, 58 years old, hypertensive and with bronchial asthmaMother, 66 years old, apparently wellSiblings: 2 siblings, with one sibling with hypertension, high cholesterol, and asthma She denies other heredofamilial diseases such as diabetes mellitus, malignancy, liver, kidney and lung disease.Personal & Social HistoryEldest among 3 siblingsGraduate with an Engineering degreeWorks as a Telecommunications specialistMarried for 7 years to a 30 year-old network engineerHas a 7 year-old daughterNon-smoker, non-alcoholic beverage drinkerGynecologic HistoryMenarche at 13 years oldSubsequent menses were regular28 32 days interval3 5 days durationModerate flow, 4 pads per day(+) Dysmenorrhea, (+) Dyspareunia(-) Post-coital bleeding, (-) LeukorrheaPap smear (2011) normalObstetrical HistoryGravida 1 Para 1 (1001)Delivered on 2007, term living girl, BW 3000g, appropriate for gestational age, via NSD at Bernardino Hospital; no fetomaternal complicationsMethod of ContraceptionOCP (2010 to 2013)DMPA (2013)Sexual HistoryCoitarche: 22 years old1 sexual partnerPartner had 2 sexual partnersIn a monogamous relationshipReview of SystemsUnremarkablePhysical ExaminationGeneral Survey: Patient is conscious, coherent, not in cardiorespiratory distress, with the following vital signs: BP: 100/70 PR: 74 bpm RR: 20 cpm Temperature: 36.8 C HEENT: Anicteric sclera, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, stye on right lower lidNeck: Supple neck, no neck vein engorgement, no cervical lymphadenopathyPhysical ExaminationChest: Symmetrical chest expansion, no retractions, no laggingLungs: Vesicular breath sounds, no crackles, no wheezes.Heart: Adynamic precordium, normal rate, regular rhythm, no murmursBreast: Symmetrical contour, no dimpling, no palpable mass, no tenderness, no abnormal nipple dischargePhysical ExaminationAbdomen: Flabby, soft, non-tender, normoactive bowel sounds, no massSpeculum exam: clean looking cervix with minimal whitish dischargeInternal exam: normal looking external genitalia, parous introitous, vagina admits two fingers with ease, cervix firm and closed, unenlarged uterus, no adnexal mass nor tendernessExtremities: No gross deformities, full and equal pulses, no edema, no cyanosisSkin: No active dermatosesDysmenorrheaPrimaryNo pelvic pathologySpasmodicSecondaryWith pelvic pathologyCongestiveDifferential DiagnosesSevere hypogastric pain (Dysmenorrhea)Ectopic pregnancyPelvic Inflammatory DiseaseAbortionEndometriosisEndometriosisPresence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction (Kennedy, et al., 2005) ESHRE Guidelines 2013EndometriosisPrevalence:2 10% of general female populationUp to 50% in infertile women

Chronic painInfertilityDiminished QOLEndometriosis, EtiologyRetrograde menstruationMetaplastic conversion of coelomic epitheliumAnatomic, Hematogenous or Lymphatic disseminationImmunologic dysfunctionGeneticsPathophysiologyMetaplasiaDisseminationEctopic endometrial tissueOvariesCul-de-sacBladderColonUretersDiaphragmPeritoneumPosterior fornixLungsProgesteroneEstrogenCytokinesProstaglandinsNeovascularizationFibrosisInfertilityPainDiagnosisHistoryPhysical ExaminationMedical Technology

Signs & SymptomsGynecologicDysmenorrheaNon-cyclical pelvic painDeep dyspareuniaInfertilityFatigue in the presence of AOTANon-gynecologicDyscheziaDysuriaHematuriaRectal bleedingShoulder painThe above symptoms (gyne & non-gyne) warrants consideration of endometriosis, esp. if associated with menstruation.It is important to note that infertile women + severe dysmenorrhea = high positive predictive value29Physical ExaminationSpeculum examinationBimanual palpationRectovaginal palpationAbdomen & PelvisPhysical ExaminationInduration and/or nodules of the rectovaginal wall, or visible vaginal nodules in the posterior vaginal fornix : Deep endometriosis

Physical ExaminationAdnexal mass: Ovarian endometrioma

Normal clinical examination does not rule out diseaseLaparoscopy with histopathology: Gold standard

LaparoscopyTransvaginal ultrasonography3D sonographyMRIBiomarkersMedical TechnologyHistology (Ovarian endometrioma/Deep infilitrating disease) to rule-out malignancyTransvaginal ultrasoundGround glass echogenicity and 1 to 4 compartments and no papillary structures with detectable blood flow


From http://www.ultrasound-images.com/Transvaginal ultrasound, E.L.Right ovary is converted to a unilocular cyst with low to medium level echoes measuring 3.2x2.5x2cmLeft ovary is converted to a unilocular cyst with low to medium level echoes measuring 2.8x2.6x2cmAdditional ImagingIf with suspicion of deep endometriosis:Bowel : Barium enema, Transvaginal or Transrectal UTZBladder : Transvaginal UTZ with full bladder, CystoscopyUreter : MRI, CT Urogram

Sensitive > SpecificTreatment GoalsRelief of painFertility, if wantedAdmitting DiagnosisGravida 1 Para 1 (1001)Secondary dysmenorrhea probably secondary to bilateral endometriotic cystsPain ManagementCounselling plusAnalgesicsCombined hormonal contraceptivesProgestagensSurgeryHormonal TherapiesHormonal contraceptivesProgestagensAnti-progestogensGnRH agonistPatient preferenceSide effectsEfficacyCostAvailabilityHormonal ContraceptivesDyspareuniaDysmenorrheaNon-menstrual painChronic pelvic painCombined hormonal contraceptiveCombined oral contraceptive pillsVaginal contraceptive ring or Transdermal patchProgestagens & Anti-progestagensMedroxyprogesterone acetate (oral or depot)DienogestCyproterone acetateNorethisterone acetateDanazolLNG-IUSGestrinoneGnRH agonistsNafarelinLeuprolideBuserelinGoserelinTriptorelinHormonal add-back therapyCaution in young & adolescent women+Aromatase InhibitorsFor rectovaginal endometriosis refractory to other medical or surgical treatmentAromatase InhibitorOCPProgestagenGnRH agonist+Aromatase inhibitors: Letrozole, AnastrozoleSevere side effects: Hypoestrogenism (vaginal dryness, hot flushes, diminished BMD), higher rate of multiple gestation44AnalgesicsNSAIDs or other analgesics may be given

Discuss risksGastric ulcerationInhibition of ovulationCardiovascular diseaseSurgeryOperative laparoscopyAblation vs. ExcisionEqual effectivenessInterruption of Pelvic Nerve PathwaysLaparoscopic Uterosacral Nerve Ablation (LUNA)Presacral NeurectomyOvarian endometriomaCystectomy vs. Drainage & CoagulationCO2 Laser VaporizationCystectomy reduces pain and recurrence rate, esp. if the endometrioma is >3cm. Drainage & coagulation does not.CO2 laser vaporization further reduces recurrence.46SurgeryDeep EndometriosisSurgical removalReferral to centre of expertiseHysterectomyHysterectomy + oophorectomy + removal of endometrial lesionsWomen with completed family; failed to respond to conservative treatmentsAdhesion PreventionOxidized regenerated celluloseOther anti-adhesion agentsPre-operative hormonal treatmentAlleviates symptoms before the surgeryNo change in outcome of surgeryPost-operative hormonal treatmentShort-term vs. Long-termLong-term therapySecondary prevention:Prevent recurrence of pain symptomsPrevent recurrence of diseaseLNG-IUS or Combined hormonal contraceptive for at least 18 24 monthsExtragenital EndometriosisSurgical removalMedical treatmentNon-medical strategiesSupplements and alternative medicine are not recommended.PlanPatient is for Laparoscopic bilateral oophorocystectomy with chromopertubationPlanFor Laparoscopic bilateral oophorocystectomy with chromopertubationNPO 6 hours prior to ORIVF once on NPO: 1L D5LR for 8 hoursFor Blood typingGive Cefuroxime 1.5 g TIV (-) ANST 1 hour prior to ORCourse in the Ward2nd Hospital Day: Patient underwent Laparoscopy, surgical with bilateral partial oophorectomy, chromopertubation and electrofulguration of endometriotic implantsPatient was discharged improved on the 4th hospital day.Laboratory ResultsBlood type: A+Histopathologic report of the bilateral ovarian cysts: results pendingLaboratory ResultsCBCHgb 150Hct 0.43Platelet count 351WBC 9.5 (0.65,0.23,0.67,0.04)UrinalysisYellow/Hazy/6.