ENDOMETRIOSISESHRE Guidelines on Endometriosis 2013

Justin W. Ng Sinco

The following will be presented:• Case Presentation• Endometriosis• Definition• Epidemiology• Etiology

• Diagnosis• Treatment of Symptoms

Case 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 Manila• Living in Camarin, Caloocan• Works as a Telecommunication specialist• Married

History of Present Illness• Menarche at 13 years old• Subsequent menses were regular• 28 – 32 days interval

• 3 – 5 days duration• Moderate flow, 4 pads per day• (+) Dysmenorrhea

History of Present Illness5 years PTC• Severe cyclic hypogastric pain• Worsened after menstruation

• Weakness and easy fatigability• No heavy bleeding, fever, dysuria, cough,

colds, headache

History of Present Illness5 years PTC• Consult at private OB• Endometriotic cyst, left ovary• Polycystic ovaries• Folic Acid 5mg OD• Vitamin B complex OD• OCP for 3 months

History of Present Illness3 years PTC• Danazol 200 mg 1 tab BID for 30 days (2012)• Injectable DMPA injected every three months

until November 2013

1 year PTC• Menstruation resumed regular cycle (May

2014)

History of Present Illness

History of Present Illness5 days PTC• Transvaginal Ultrasound

• Anteverted, normal-sized uterus with proliferative endometrium (0.6 cm)

• Right ovary is converted to a unilocular cyst with low to medium level echoes measuring 3.2x2.5x2cm

• Left ovary is converted to a unilocular cyst with low to medium level echoes measuring 2.8x2.6x2cm

• Cervix is unremarkable

• Dx: G1P1 (1001); AUB secondary to Bilateral Endometriotic Cysts

Past Medical History

• Had mumps during childhood• Bronchial asthma: last attack 1995 –

1996• Non-hypertensive, non-diabetic• No known allergies to food and drugs• No history of prior hospitalization

Family History

• Father, 58 years old, hypertensive and with bronchial asthma• Mother, 66 years old, apparently well• Siblings: 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 History• Eldest among 3 siblings• Graduate with an Engineering degree• Works as a Telecommunications specialist• Married for 7 years to a 30 year-old

network engineer• Has a 7 year-old daughter• Non-smoker, non-alcoholic beverage

drinker

Gynecologic History

• Menarche at 13 years old• Subsequent menses were regular• 28 – 32 days interval

• 3 – 5 days duration• Moderate flow, 4 pads per day• (+) Dysmenorrhea, (+) Dyspareunia• (-) Post-coital bleeding, (-) Leukorrhea• Pap smear (2011) – normal

Obstetrical History

• Gravida 1 Para 1 (1001)• Delivered on 2007, term living girl, BW

3000g, appropriate for gestational age, via NSD at Bernardino Hospital; no fetomaternal complications

Method of Contraception• OCP (2010 to 2013)• DMPA (2013)

Sexual History

• Coitarche: 22 years old• 1 sexual partner• Partner had 2 sexual partners

• In a monogamous relationship

Review of Systems

• Unremarkable

Physical Examination

• General 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 lid• Neck: Supple neck, no neck vein

engorgement, no cervical lymphadenopathy

Physical Examination

• Chest: Symmetrical chest expansion, no retractions, no lagging• Lungs: Vesicular breath sounds, no

crackles, no wheezes.• Heart: Adynamic precordium, normal

rate, regular rhythm, no murmurs• Breast: Symmetrical contour, no

dimpling, no palpable mass, no tenderness, no abnormal nipple discharge

Physical Examination

• Abdomen: Flabby, soft, non-tender, normoactive bowel sounds, no mass• Speculum exam: clean looking cervix with

minimal whitish discharge• Internal exam: normal looking external

genitalia, parous introitous, vagina admits two fingers with ease, cervix firm and closed, unenlarged uterus, no adnexal mass nor tenderness• Extremities: No gross deformities, full and

equal pulses, no edema, no cyanosis• Skin: No active dermatoses

Dysmenorrhea

Primary

• No pelvic pathology• Spasmodic

Secondary

• With pelvic pathology• Congestive

Differential Diagnoses

Severe hypogastric pain (Dysmenorrhea)

Ectopic pregnancy

Pelvic Inflammatory Disease

Abortion

Endometriosis

EndometriosisPresence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction (Kennedy, et al., 2005) ESHRE Guidelines 2013

Endometriosis

Prevalence:• 2 – 10% of general female

population• Up to 50% in infertile women

Chronic pain

Infertility

Diminished QOL

Endometriosis, Etiology

• Retrograde menstruation• Metaplastic conversion of coelomic

epithelium• Anatomic, Hematogenous or Lymphatic

dissemination• Immunologic dysfunction• Genetics

Path

op

hysio

log

yMetaplasia Dissemination

Ectopic endometrial tissue

OvariesCul-de-sacBladderColonUreters

DiaphragmPeritoneumPosterior fornixLungs

ProgesteroneEstrogen

CytokinesProstaglandins

NeovascularizationFibrosis

INFERTILITYPAIN

Diagnosis

• History• Physical Examination• Medical Technology

Signs & Symptoms

Gynecologic

• Dysmenorrhea• Non-cyclical pelvic

pain• Deep dyspareunia• Infertility• Fatigue in the

presence of AOTA

Non-gynecologic

• Dyschezia• Dysuria• Hematuria• Rectal bleeding• Shoulder pain

Physical Examination

• Speculum examination• Bimanual palpation• Rectovaginal palpation• Abdomen & Pelvis

Physical Examination

• Induration and/or nodules of the rectovaginal wall, or visible vaginal nodules in the posterior vaginal fornix : Deep endometriosis

Physical Examination

• Adnexal mass: Ovarian endometrioma

• Normal clinical examination does not rule out disease

• Laparoscopy with histopathology: Gold standard

• Laparoscopy• Transvaginal ultrasonography• 3D sonography• MRI• Biomarkers

Medical Technology

Histology (Ovarian endometrioma/Deep infilitrating disease) to rule-out malignancy

Transvaginal ultrasound

Ground glass echogenicity and 1 to 4 compartments and no papillary structures with detectable blood flow

OvarianEndometrioma

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 3.2x2.5x2cm• Left ovary is converted to a unilocular

cyst with low to medium level echoes measuring 2.8x2.6x2cm

Additional Imaging

If with suspicion of deep endometriosis:• Bowel : Barium enema, Transvaginal or

Transrectal UTZ• Bladder : Transvaginal UTZ with full

bladder, Cystoscopy• Ureter : MRI, CT Urogram

Sensitive > Specific

Treatment Goals

• Relief of pain• Fertility, if wanted

Admitting DiagnosisGravida 1 Para 1 (1001)

Secondary dysmenorrhea probably secondary to bilateral endometriotic cysts

Pain Management

• Counselling plus• Analgesics• Combined hormonal contraceptives• Progestagens

• Surgery

Hormonal Therapies

Hormonal contraceptives

Progestagens

Anti-progestogens

GnRH agonist

Patient preference

Side effects

Efficacy

Cost

Availability

Hormonal Contraceptives

Dyspareunia

Dysmenorrhea

Non-menstrual pain

Chronic pelvic pain

Combined hormonal contraceptive

Combined oral contraceptive pills

Vaginal contraceptive ring or Transdermal patch

Progestagens & Anti-progestagens• Medroxyprogesterone acetate (oral or

depot)• Dienogest• Cyproterone acetate• Norethisterone acetate• Danazol• LNG-IUS• Gestrinone

GnRH agonists

• Nafarelin• Leuprolide• Buserelin• Goserelin• Triptorelin

Hormonal add-back therapy

Caution in young & adolescent women

+

Aromatase Inhibitors

• For rectovaginal endometriosis refractory to other medical or surgical treatment

Aromatase Inhibitor

OCPProgestagenGnRH agonist

+

Analgesics

• NSAIDs or other analgesics may be given

• Discuss risks• Gastric ulceration• Inhibition of ovulation• Cardiovascular disease

Surgery

1. Operative laparoscopy• Ablation vs. Excision

• Equal effectiveness

2. Interruption of Pelvic Nerve Pathways• Laparoscopic Uterosacral Nerve Ablation

(LUNA)• Presacral Neurectomy

3. Ovarian endometrioma• Cystectomy vs. Drainage & Coagulation• CO2 Laser Vaporization

Surgery

4. Deep Endometriosis• Surgical removal• Referral to centre of expertise

5. Hysterectomy• Hysterectomy + oophorectomy + removal of

endometrial lesions• Women with completed family; failed to

respond to conservative treatments

6. Adhesion Prevention• Oxidized regenerated cellulose• Other anti-adhesion agents

Pre-operative hormonal treatment• Alleviates symptoms before the surgery• No change in outcome of surgery

Post-operative hormonal treatment• Short-term vs. Long-term• Long-term therapy• Secondary prevention:

• Prevent recurrence of pain symptoms• Prevent recurrence of disease

• LNG-IUS or Combined hormonal contraceptive for at least 18 – 24 months

Extragenital Endometriosis• Surgical removal• Medical treatment

Non-medical strategies

• Supplements and alternative medicine are not recommended.

PlanPatient is for Laparoscopic bilateral oophorocystectomy with chromopertubation

Plan

• For Laparoscopic bilateral oophorocystectomy with chromopertubation• NPO 6 hours prior to OR

• IVF once on NPO: 1L D5LR for 8 hours• For Blood typing• Give Cefuroxime 1.5 g TIV (-) ANST 1

hour prior to OR

Course in the Ward

• 2nd Hospital Day: Patient underwent Laparoscopy, surgical with bilateral partial oophorectomy, chromopertubation and electrofulguration of endometriotic implants• Patient was discharged improved on the

4th hospital day.

Laboratory Results

• Blood type: “A+”• Histopathologic report of the bilateral

ovarian cysts: results pending

Laboratory Results

• CBC• Hgb 150• Hct 0.43• Platelet count 351• WBC 9.5 (0.65,0.23,0.67,0.04)

• Urinalysis• Yellow/Hazy/6.0/1.015/Neg/Neg/1-2/0-2

Laboratory Results

• FBS 5.8• BUN 3.85• Crea 64.7• SGPT 19.7• SGOT 13.8• Na 139• K 4.4• Ca 1.10

Laboratory Results

• CXR: Normal• ECG: Sinus rhythm

Operation Technique

• Ovarian epithelium covering the cysts were excised; edges of the cyst were stripped from the normal ovarian tissue.

Intra-operative findings

• No ascites. Liver, spleen, subdiaphragmatic surface and bowel were smooth• Uterine corpus was retroverted with smooth,

pinkish serosa. Posterior cul-de-sac has multiple endometriotic implants.• Left ovary was cystically enlarged to 5x5cm

with a unilocular cyst measuring 3x2cm exuding chocolate-brown fluid• Right ovary was likewise enlarged to 4x3cm

with a 1 cm cystic mass exuding chocolate-brown fluid

Intra-operative findings

• Both fallopian tubes were grossly normal with egress of methylene blue on chromopertubation. The rest of the abdomino-pelvic organs are grossly normal

Post-operative DiagnosisGravida 1 Para 1 (1001)

Pelvic endometriosis AFS Stage III with bilateral endometrioma

Treatment of Infertility

• Medical• Surgical• Medical adjunct to surgery• Alternative treatments

Hormonal therapy

• Not effective

• Not recommended

Adjunct Hormonal therapy

Surgery

• Operative laparoscopy + adhesiolysis

• CO2 Laser vaporization vs. Monopolar electrocoagulation• Excision of endometrioma capsule• Counselling

Non-medical strategies

• Supplements and alternative medicine are not recommended.

Assisted reproduction

• Intrauterine insemination with controlled ovarian stimulation within 6 months after surgical treatment• Assisted reproductive technology

(IVS/ICSI) is recommended• GnRH agonist for 3 to 6 months prior

Menopause & Endometriosis• Estrogen/Progestagen therapy or

Tibolone reduces menopausal symptoms in surgically-induced menopause• Given at least up to the age of natural

menopause

Asymptomatic Endometriosis• Incidental findings of ectopic foci with no

pelvic pain or infertility.• Surgical excision and ablation are not

recommended

Prevention of Endometriosis• Etiology is unknown, thus primary

prevention is uncertain• Oral contraceptives : uncertain• Exercise : uncertain