Endometriosis Dr.Mona Shroff M.D. Endometriosis Definition: Ectopic Endometrial Tissue Definition:...

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Transcript of Endometriosis Dr.Mona Shroff M.D. Endometriosis Definition: Ectopic Endometrial Tissue Definition:...

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Endometriosis Dr.Mona Shroff M.D Slide 2 Endometriosis Definition: Ectopic Endometrial Tissue Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% True Incidence Unknown: ? 1-5% Does NOT Discriminate by Race Does NOT Discriminate by Race Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction Slide 3 - Pelvic - Extra pelvic Umbilicus. Umbilicus. Scars (Lap.). Scars (Lap.). Lungs & plura. Lungs & plura. Others. Others. Slide 4 Uterine= Adenomyosis (50%). Uterine= Adenomyosis (50%). Extraut: Extraut: - Ovary 30% - Pelvic peritoneum 10%. - F. tube. - Vagina. -Bladder & rectum. - Pelvic colon. - Ligaments. Slide 5 Slide 6 Prevalence Slide 7 Age at Diagnosis < 19 6% 19 25 24% 26 35 52% 36 45 15% > 45 3% Slide 8 Signs and Symptoms Chronic Pelvic Pain, Dysmenorrhea Chronic Pelvic Pain, Dysmenorrhea Abnormal Uterine Bleeding Abnormal Uterine Bleeding Infertility Infertility Deep Dyspareunia Deep Dyspareunia Pelvic Mass (Endometrioma) Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, Hemoptysis Misc: Tenesmus, Hematuria, Hemoptysis Slide 9 Pelvic examination may reveal: 1. Pelvic tenderness. 1. Pelvic tenderness. 2. Fixed retroverted uterus. 2. Fixed retroverted uterus. 3. Nodularity of the Douglas pouch and uterosacral ligaments. 3. Nodularity of the Douglas pouch and uterosacral ligaments. 4. Ovaries may be enlarged and tender. Ovarian cyst may be detected. 4. Ovaries may be enlarged and tender. Ovarian cyst may be detected. Slide 10 Etiology: Theories Sampson: Retrograde Menstruation Sampson: Retrograde Menstruation Hematologic Spread Hematologic Spread Lymphatic Spread Lymphatic Spread Coelomic Metaplasia Coelomic Metaplasia Genetic Factors Genetic Factors Immune Factors Immune Factors Combination of the Above Combination of the Above No Single Theory Explains All Cases of Endometriosis Slide 11 Diagnosis Laparoscopy (Gold Standard) Laparoscopy (Gold Standard) Laparotomy Laparotomy Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies Biopsy Preferable Over Visual Inspection Biopsy Preferable Over Visual Inspection Slide 12 Appearance Endometriosis May Appear Brown Brown Black (Powderburn) Black (Powderburn) Clear (Atypical) Clear (Atypical) Endometriosis May Be Associated with Peritoneal Windows Slide 13 Slide 14 Slide 15 Slide 16 Treatment: Overall Approach Recognize Goals: Recognize Goals: Pain Management Preservation / Restoration of Fertility Discuss with Patient: Discuss with Patient: Disease may be Chronic and Not Curable Optimal Treatment Unproven or Nonexistent Slide 17 Treatment : Consideration Age. Age. Symptoms. Symptoms. Stage. Stage. Infertility. Infertility. Slide 18 Classification / Staging Several Proposed Schemes Several Proposed Schemes Revised AFS System: Most Often Used Revised AFS System: Most Often Used Ranges from Stage I (Minimal) to Stage IV (Severe) Ranges from Stage I (Minimal) to Stage IV (Severe) Staging Involves Location and Depth of Disease, Extent of Adhesions Staging Involves Location and Depth of Disease, Extent of Adhesions Slide 19 Slide 20 Pain Management: Medical Therapy NSAIDs NSAIDs OCPs (Continuous) OCPs (Continuous) Progestins Progestins Danazol Danazol GnRH-a GnRH-a GnRH-a + Add-Back Therapy GnRH-a + Add-Back Therapy Misc: Opoids, SSRIs Misc: Opoids, SSRIs Slide 21 Indications of Hormonal ttt 1. Small endometriotic; lesions. 2. Recurrence after conservative surgery. 3. Preoperative for 6-12 weeks to decrease size. 4. Postoperative for residual lesions. 5. When operation is contraindicated or refused by the patient. Slide 22 Aim of the hormonal therapy (A) Pseudopregnancy : 1. Combined low - dose contraceptive pills(6 - 18 months to inhibit ovulation and menstruation and induce decidualization to endometriotic tissues). or 2. Progestins (to avoid oestrogen's side effects medroxy progesterone acetate Depo medroxy progesterone acetate (DMPA) can be given in a dose of 150 mg IM every I - 3 months. Slide 23 Aim of the hormonal therapy cont. (B) Pseudomenopause (induction of amenorrhoea) by: 1. Danazol. 1. Danazol. 2. Gn RH analogues. 2. Gn RH analogues. 3. Gestrinone. 3. Gestrinone. 4. Gossypol. 4. Gossypol. Slide 24 Continuous OCPs Pseudopregnancy (Kistner) Pseudopregnancy (Kistner) ? Minimizes Retrograde Menstruation ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Treatments Lower Fertility Rates than Other Medical Treatments Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects Slide 25 Progestins May be as Effective as GnRH-a for Pain Control May be as Effective as GnRH-a for Pain Control MPA 10-30 mg/day, DP 150 mg Semi-Monthly MPA 10-30 mg/day, DP 150 mg Semi-Monthly May be Taken Long-Term May be Taken Long-Term Relatively Inexpensive Relatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea Slide 26 Danazol Weak Androgen Weak Androgen Suppresses LH / FSH Suppresses LH / FSH Causes Endometrial Regression, Atrophy Causes Endometrial Regression, Atrophy Expensive Expensive Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes Slide 27 GnRH-a (Leuprolide,triptorelin) Initially Stimulate FSH / LH Release Initially Stimulate FSH / LH Release Down-Regulates GnRH Receptors Pseudomenopause Down-Regulates GnRH Receptors Pseudomenopause Long-Term Success Varies Long-Term Success Varies Expensive Expensive Use Limited by Hypoestrogenic Effects Use Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1 Year ) May be Combined with Add-Back (? >1 Year ) Slide 28 Gestrinone It is a synthetic 19 Nor steroid exhibits marked and - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties. It is a synthetic 19 Nor steroid exhibits marked and - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties. The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of ovarian steroidogenesis. The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of ovarian steroidogenesis. The dose is 2.5 - 5 mg orally twice weekly. The dose is 2.5 - 5 mg orally twice weekly. Slide 29 Surgical Treatment (Laparoscopy / Laparotomy) Excision / Fulgration ( ELECTROCAUTRY/LASER) Excision / Fulgration ( ELECTROCAUTRY/LASER) Resection of Endometrioma Resection of Endometrioma Lysis of Adhesions, Cul-de-sac Reconstruction Lysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve Ablation Uterosacral Nerve Ablation Presacral Neurectomy Presacral Neurectomy Appendectomy Appendectomy Uterine Suspension (? Efficacy) Uterine Suspension (? Efficacy) Hysterectomy +/- BSO Hysterectomy +/- BSO Slide 30 Issues ? Removal of Ovaries at Hysterectomy ? Removal of Ovaries at Hysterectomy ? Need for Progestins if ERT Given ? Need for Progestins if ERT Given ? Adjuvant Treatment Postoperatively ? Adjuvant Treatment Postoperatively ? Lupron Challenge Test for Diagnosis ? Lupron Challenge Test for Diagnosis ? Is Endometriosis Best Treated Surgically, Medically or Both ? Is Endometriosis Best Treated Surgically, Medically or Both Slide 31 Conclusion Endometriosis is a Common, Chronic Disease Endometriosis is a Common, Chronic Disease Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding The Optimal Treatment Remains Unclear The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious Approach with Respect to Fertility Surgical Excision is the Most Efficacious Approach with Respect to Fertility Better Medical Therapies are Needed Better Medical Therapies are Needed