EndometriosisEndometriosis

Dr.Mona Shroff M.DDr.Mona Shroff M.D

Endometriosis Endometriosis

Definition: Ectopic Endometrial TissueDefinition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5%True Incidence Unknown: ? 1-5% Does NOT Discriminate by RaceDoes NOT Discriminate by Race Histology: Endometrial Glands with Stroma Histology: Endometrial Glands with Stroma

+/- Inflammatory Reaction+/- Inflammatory Reaction

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

Uterine= Adenomyosis (50%).Uterine= Adenomyosis (50%). Extraut:Extraut:

- Ovary 30%- Ovary 30%

- Pelvic peritoneum 10%.- Pelvic peritoneum 10%.

- F. tube.- F. tube.

- Vagina.- Vagina.

-Bladder & rectum.-Bladder & rectum.

- Pelvic colon.- Pelvic colon.

- Ligaments.- Ligaments.

PrevalencePrevalence

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

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/1000w oman-years

Prevalence = 7.5%Endometriosis Affects ~5

Million W omen, 30-40%are Infertile

Age at DiagnosisAge at Diagnosis

< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%

Signs and Symptoms Signs and Symptoms

Chronic Pelvic Pain, DysmenorrheaChronic Pelvic Pain, Dysmenorrhea Abnormal Uterine BleedingAbnormal Uterine Bleeding InfertilityInfertility Deep DyspareuniaDeep Dyspareunia Pelvic Mass (Endometrioma)Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, HemoptysisMisc: Tenesmus, Hematuria, Hemoptysis

Pelvic examination may reveal:Pelvic examination may reveal: 1. 1. Pelvic tenderness.Pelvic tenderness.

2.2. Fixed retroverted uterus. Fixed retroverted uterus.

3.3. Nodularity of the Douglas pouch and Nodularity of the Douglas pouch and uterosacral ligaments.uterosacral ligaments.

4. Ovaries4. Ovaries may may be be enlarged and tender . Ovarian enlarged and tender . Ovarian cyst maycyst may be be detected. detected.

Etiology: TheoriesEtiology: Theories

Sampson: “Retrograde Menstruation”Sampson: “Retrograde Menstruation” Hematologic SpreadHematologic Spread Lymphatic SpreadLymphatic Spread Coelomic MetaplasiaCoelomic Metaplasia Genetic FactorsGenetic Factors Immune FactorsImmune Factors Combination of the AboveCombination of the AboveNo Single Theory Explains All Cases of Endometriosis No Single Theory Explains All Cases of Endometriosis

Diagnosis Diagnosis

Laparoscopy (“Gold Standard)Laparoscopy (“Gold Standard) LaparotomyLaparotomy Inconclusive: CA-125, Pelvic Exam, Inconclusive: CA-125, Pelvic Exam,

History, Imaging StudiesHistory, Imaging Studies Biopsy Preferable Over Visual InspectionBiopsy Preferable Over Visual Inspection

AppearanceAppearance

Endometriosis May AppearEndometriosis May AppearBrownBrownBlack (“Powderburn”)Black (“Powderburn”)Clear (“Atypical”)Clear (“Atypical”)

Endometriosis May Be Associated with Endometriosis May Be Associated with Peritoneal WindowsPeritoneal Windows

Treatment: Overall ApproachTreatment: Overall Approach

Recognize Goals: Recognize Goals:

–– Pain ManagementPain Management

–– Preservation / Restoration of FertilityPreservation / Restoration of Fertility Discuss with Patient:Discuss with Patient:

–– Disease may be Chronic and Not CurableDisease may be Chronic and Not Curable

–– Optimal Treatment Unproven or Optimal Treatment Unproven or Nonexistent Nonexistent

Treatment : ConsiderationTreatment : Consideration

Age.Age.

Symptoms.Symptoms.

Stage.Stage.

Infertility.Infertility.

Classification / StagingClassification / Staging

Several Proposed SchemesSeveral Proposed Schemes Revised AFS System: Most Often UsedRevised AFS System: Most Often Used Ranges from Stage I (Minimal) to Stage IV Ranges from Stage I (Minimal) to Stage IV

(Severe)(Severe) Staging Involves Location and Depth of Staging Involves Location and Depth of

Disease, Extent of AdhesionsDisease, Extent of Adhesions

Pain Management: Medical Pain Management: Medical TherapyTherapy

NSAIDsNSAIDs OCPs (Continuous)OCPs (Continuous) ProgestinsProgestins DanazolDanazol GnRH-aGnRH-a GnRH-a + Add-Back TherapyGnRH-a + Add-Back Therapy Misc: Opoids, SSRIsMisc: Opoids, SSRIs

Indications of Hormonal tttIndications of Hormonal ttt

1. Small endometriotic; lesions.1. Small endometriotic; lesions.2. Recurrence after conservative surgery.2. Recurrence after conservative surgery.3. Preoperative for 6-12 weeks to decrease 3. Preoperative for 6-12 weeks to decrease

size.size.4. Postoperative for residual lesions.4. Postoperative for residual lesions.5. When operation is contraindicated or 5. When operation is contraindicated or

refused by the patient.refused by the patient.

Aim of the hormonal therapyAim of the hormonal therapy(A) Pseudopregnancy :(A) Pseudopregnancy :1. 1. Combined low - dose contraceptive pills(6 - 18 Combined low - dose contraceptive pills(6 - 18

months to inhibit ovulation and menstruation and months to inhibit ovulation and menstruation and induce decidualization to endometriotic tissues).induce decidualization to endometriotic tissues).

oror2. 2. Progestins (to avoid oestrogen's side effects Progestins (to avoid oestrogen's side effects

medroxy progesterone acetate Depo medroxy medroxy progesterone acetate Depo medroxy progesterone acetate (DMPA) can be given in a progesterone acetate (DMPA) can be given in a dose of 150 mg IM every I - 3 months .dose of 150 mg IM every I - 3 months .

Aim of the hormonal therapy Aim of the hormonal therapy cont….cont….

(B) Pseudomenopause (induction (B) Pseudomenopause (induction of amenorrhoea) by:of amenorrhoea) by:

1. Danazol.1. Danazol.

2. Gn RH analogues.2. Gn RH analogues.

3. Gestrinone.3. Gestrinone.

4. Gossypol.4. Gossypol.

Continuous OCPsContinuous OCPs

““Pseudopregnancy” (Kistner)Pseudopregnancy” (Kistner) ? Minimizes Retrograde Menstruation? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Lower Fertility Rates than Other Medical

TreatmentsTreatments Choose OCPs with Least Estrogenic Choose OCPs with Least Estrogenic

Effects, Maximal Androgenic / Progestin Effects, Maximal Androgenic / Progestin EffectsEffects

ProgestinsProgestins

May be as Effective as GnRH-a for Pain ControlMay be as Effective as GnRH-a for Pain Control MPA 10-30 mg/day, DP 150 mg Semi-MonthlyMPA 10-30 mg/day, DP 150 mg Semi-Monthly May be Taken Long-TermMay be Taken Long-Term Relatively InexpensiveRelatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Side-Effects: AUB, Mood Swings, Weight Gain,

AmenorrheaAmenorrhea

DanazolDanazol

Weak AndrogenWeak Androgen Suppresses LH / FSHSuppresses LH / FSH Causes Endometrial Regression, AtrophyCauses Endometrial Regression, Atrophy ExpensiveExpensive Side-Effects: Weight Gain, Side-Effects: Weight Gain,

Masculinization, Occ. Permanent Vocal Masculinization, Occ. Permanent Vocal ChangesChanges

GnRH-a (Leuprolide,triptorelin)GnRH-a (Leuprolide,triptorelin)

Initially Stimulate FSH / LH ReleaseInitially Stimulate FSH / LH Release Down-Regulates GnRH Down-Regulates GnRH

Receptors–”Pseudomenopause”Receptors–”Pseudomenopause” Long-Term Success VariesLong-Term Success Varies ExpensiveExpensive Use Limited by Hypoestrogenic EffectsUse Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1 Year )May be Combined with Add-Back (? >1 Year )

GestrinoneGestrinone It is a synthetic 19 Nor steroid exhibits marked and It is a synthetic 19 Nor steroid exhibits marked and

- progcs-terogenic and anti - oestrogenic as well as - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties mild androgenic and anti -gonadotrophic properties ..

The endocrine effects of Gestrinone are similar to The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of those of Danazol which leads mainly to inhibition of ovari an steroidogenesis . ovari an steroidogenesis .

The dose is 2.5 - 5 mg orally twice weekly .The dose is 2.5 - 5 mg orally twice weekly .

Surgical Treatment Surgical Treatment (Laparoscopy / Laparotomy)(Laparoscopy / Laparotomy)

Excision Excision // Fulgration Fulgration((ELECTROCAUTRY/LASER)ELECTROCAUTRY/LASER)

Resection of EndometriomaResection of Endometrioma Lysis of Adhesions, Cul-de-sac ReconstructionLysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve AblationUterosacral Nerve Ablation Presacral NeurectomyPresacral Neurectomy AppendectomyAppendectomy Uterine Suspension (? Efficacy)Uterine Suspension (? Efficacy) Hysterectomy +/- BSOHysterectomy +/- BSO

IssuesIssues

? 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, ? Is Endometriosis Best Treated Surgically,

Medically or Both Medically or Both

ConclusionConclusion

Endometriosis is a Common, Chronic Endometriosis is a Common, Chronic Disease Disease

Typical Symptoms Include Pain, Infertility, Typical Symptoms Include Pain, Infertility, Abnormal Uterine BleedingAbnormal Uterine Bleeding

The Optimal Treatment Remains UnclearThe Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious Surgical Excision is the Most Efficacious

Approach with Respect to FertilityApproach with Respect to Fertility Better Medical Therapies are NeededBetter Medical Therapies are Needed