Endometriosis

Assoc.Prof.Pawin Puapornpong,

Faculty of Medicine,

Srinakharinwirot University.

Endometriosis

Definition: Ectopic Endometrial Tissue

True Incidence Unknown: ? 1-5%

Does NOT Discriminate by Race

Histology: Endometrial Glands with Stroma

+/- Inflammatory Reaction

Signs and Symptoms

Chronic Pelvic Pain, Dysmenorrhea

Abnormal Uterine Bleeding

Infertility

Deep Dyspareunia

Pelvic Mass (Endometrioma)

Misc: Tenesmus, Hematuria, LBP,

Hemoptysis

Prevalence

Surgical Series (Uncontrolled) 1 – 53%

Surgical Series (Controlled) 23 – 47% (Infertile)

1 – 5% (Fertile)

Population-Based Studies 6.2 –7.9%

Epidemiological Study 0.25 new cases/1000 woman-years

Prevalence = 7.5%

Endometriosis Affects ~5 Million Women,

30-40% are Infertile

Surgical Series (Uncontrolled) 1 – 53%

Surgical Series (Controlled) 23 – 47% (Infertile)1 – 5% (Fertile)

Population-Based Studies 6.2 –7.9%

Epidemiological Study 0.25 new cases/1000woman-years

Prevalence = 7.5%Endometriosis Affects ~5

Million Women, 30-40%are Infertile

Age at Diagnosis

< 19 6%

19 – 25 24%

26 –35 52%

36 –45 15%

> 45 3%

Etiology: Theories

Sampson: “Retrograde Menstruation”

Hematologic Spread

Lymphatic Spread

Coelomic Metaplasia

Genetic Factors

Immune Factors

Combination of the Above No Single Theory Explains All Cases of Endometriosis

Diagnosis

Laparoscopy (“Gold Standard)

Laparotomy

Inconclusive: CA-125, Pelvic Exam,

History, Imaging Studies

Biopsy Preferable Over Visual Inspection

Appearance

Endometriosis May Appear

Brown

Black (“Powderburn”)

Clear (“Atypical”)

Endometriosis May Be Associated with

Peritoneal Windows

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

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

Pain Management: Medical

Therapy

NSAIDs

OCPs (Continuous)

Progestins

Danazol

GnRH-a

GnRH-a + Add-Back Therapy

Misc: Opoids, TCAs, SSRIs

Continuous OCPs

“Pseudopregnancy” (Kistner)

? Minimizes Retrograde Menstruation

Lower Fertility Rates than Other Medical

Treatments

Choose OCPs with Least Estrogenic

Effects, Maximal Androgenic / Progestin

Effects

Progestins

May be as Effective as GnRH-a for Pain Control

MPA 10-30 mg/day, DP 150 mg Semi-Monthly

May be Taken Long-Term

Relatively Inexpensive

Side-Effects: AUB, Mood Swings, Weight Gain,

Amenorrhea

Danazol

Weak Androgen

Suppresses LH / FSH

Causes Endometrial Regression, Atrophy

Expensive

Side-Effects: Weight Gain, Masculinization,

Occ. Permanent Vocal Changes

GnRH-a

Initially Stimulate FSH / LH Release

Down-Regulates GnRH Receptors–

”Pseudomenopause”

Long-Term Success Varies

Expensive

Use Limited by Hypoestrogenic Effects

May be Combined with Add-Back (? >1 Year )

Surgical Treatment

(Laparoscopy / Laparotomy) Excision/ Fulgeration

Resection of Endometrioma

Lysis of Adhesions, Cul-de-sac Reconstruction

Uterosacral Nerve Ablation

Presacral Neurectomy

Appendectomy

Uterine Suspension (? Efficacy)

Hysterectomy +/- BSO

Issues

? Removal of Ovaries at Hysterectomy

? Need for Progestins if ERT Given

? Adjuvant Treatment Postoperatively

? Lupron Challenge Test for Diagnosis

? Is Endometriosis Best Treated Surgically,

Medically or Both

Conclusion

Endometriosis is a Common, Chronic Disease

Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding

The Optimal Treatment Remains Unclear

Surgical Excision is the Most Efficacious Approach with Respect to Fertility

Better Medical Therapies are Needed

Thank you