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Endometrio sis Update (Clinic)

Endometrio sis Update (Clinic). Dr.Engin Oral Cerrahpaşa Medical Faculty Department of Obstet & Gynecology Div of Reproductive Endocrinology. Endometriosis : Diagnosis process. 4,334 women reporting surgically diagnosed endometriosis.

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Endometrio sis Update (Clinic)

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  1. Endometriosis Update(Clinic) Dr.Engin Oral Cerrahpaşa Medical Faculty Department of Obstet & Gynecology Div of Reproductive Endocrinology

  2. Endometriosis:Diagnosisprocess 4,334 women reporting surgically diagnosed endometriosis Onsetof Time fromseekingsymptomsmedical attentionto diagnosis Adolescents 6.0 ± 0.2 years Adults 2.0 ± 0.3 years Onset of symptoms Adolescents 67.1% Adults 39.2% Greene R, 2009

  3. 2009

  4. Markham R. Endometriosis symptoms in Australian women (PhD Thesis). The University of Sydney. 2002.

  5. Deep Endometriosis: Symptoms Pandis GK, 2010

  6. Diagnosis of Endometriosis • History(The most important) • Symptoms • PhysicalExamination(not much help) • Serum Markers(Lacks sensitivity) • Ultrasound(of little valueexceptendometrioma) • MagneticResonanceImaging (MRI) (a good guess!) • OtherImagingModalities • immunoscintigraphy and positron emission tomography • TransvaginalHydrolaparoscopy • Laparoscopic Visualization of the Pelvis(The gold standard) • Biopsy Preferable Over Visual Inspection • NovelDiagnostic Test Rule out other Causes of Symptoms (The next mostimportant)

  7. BRANDI S. MCLEOD, and MATTHEW G. RETZLOFF, 2010

  8. Sites of Endometriosis: Associated Signs & Symptoms • Female reproductive organs (for example: ovaries, uterus, vagina, • fallopian tubes, pelvic peritoneum) • Dysmenorrhea (painful menstruation) • Dyspareunia (pain during or after sexual intercourse) • Infertility • Pelvic pain • Backache • Menstruelirregularity • Ruptured endometrioma • Surgicalscarsumbilicus • Cyclicpainandbleeding

  9. Sites of Endometriosis: Associated Signs & Symptoms • Gastrointestinal system (for example: rectum, small intestine, colon) • Nausea and vomiting • Abdominal cramping • Diarrhea • Constipation • Blood in stool • Pain in the low back or tailbone • Pain in the umbilicus • Abdominal bloating and cramping • Rectal bleeding • Defecation problems

  10. Sites of Endometriosis: Associated Signs & Symptoms • Urinary tract (for example: bladder, ureter, urethra, kidney) • Pain or burning upon urination • Urinary frequency, urgency, or retention • Blood in the urine • Flank pain • Recurrent complaints of urinary tract infections with negative cultures • Pulmonary (for example: lungs, pleura, diaphragm) • Chest or shoulder pain • Coughing up blood • Shortness of breath

  11. SERENA DOVEY, and JOSEPH SANFILIPPO, 2010

  12. Endometriomas in adolescents CA-125 of 379 and an elevated lactate dehydrogenase (LDH) of 245. Kelly Nicole Wright, 2010

  13. Deeppelvicendometriosis

  14. Three-DimensionalSonographicCharacteristics of DeepEndometriosis StefanoGuerriero, 2009

  15. Posterior pelvis endometriosisMRI The right uterosacral ligament demonstrates nodular thickening with spiculated borders (black arrow). Histology after surgical resection diagnosed endometriosis of the right uterosacral ligament.

  16. Diagnostic accuracy of physical examination,transvaginalsonography, rectalendoscopicsonography, and magnetic resonance imagingtodiagnosedeepinfiltratingendometriosis N:92 MarcBazot, 2009

  17. Urinary tract endometriosis (UTE) • Urinary tract endometriosis (UTE) includes the presence ofendometrial tissue in or around the bladder, ureters, urethra,or kidney. This disease, once considered to be a rare clinicalentity, is now increasingly recognized . • Recently, its incidencewas estimated to range from 0.3% to 6% amongwomen with endometriosis . The percentage of bladderinvolvement in these cases is 84%–90% . • Within the urinary system, the bladder is the most commonlyaffected (80%-84%), followed by the ureter(15%), kidney (4%), and urethra (2%). • In the bladder, the retrotrigone and dome are the most frequently affectedsites. Two possible ureteral lesions must be considered:intrinsic and extrinsic.

  18. Endometriosis of thebladder

  19. Endoscopic view ofbladder endometriosis

  20. AbdominalWallEndometriomasNearCesareanDeliveryScars Giampiero Francica, 2003

  21. Fine-NeedleAspirationCytology of ScarEndometriosis:Study of Seven Cases And Literature Review Francisco dasChagasMedeiros 2010

  22. Comparison of the clinical value of CA19-9 versus CA 125 for the diagnosis ofendometriosis N:101 Zehra Kurdoglu, 2009

  23. The role of microRNAs inendometriosis E. Maria C. Ohlsson Teague, 2010

  24. Epigenetics of endometriosis Sun-Wei Guo, 2009

  25. Combination of CCR1 mRNA, MCP1, and CA125 Measurements inPeripheral Blood as a Diagnostic Test for Endometriosis sensitivity of 92.2%, a specificity of81.6%, a negative predictive value of 83.3%, a positive predictive value of 92.3%, a likelihood ratioof a positive test result of 5.017, and a likelihood ratio of a negative test result of 0.096 to predict thepresence or absence of endometriosis. AdmirAgic, 2010

  26. Non-invasivediagnosis of endometriosis based on a combinedanalysis of six plasma biomarkers interleukin (IL)-6, IL-8, tumour necrosis factor-alpha, high-sensitivity C-reactive protein (hsCRP), and cancer antigens CA-125 and CA-19-9 A. Mihalyi, 2009

  27. Peripheral biomarkers ofendometriosis: a systematic review Peripheral biomarkers show promise as diagnostic aids, but further research is necessary before they can be recommended in routine clinical care. Panels of markers may allow increased sensitivity and specificity of any diagnostic test. K.E. May, 2010

  28. Visual representation of nerve fibers present in the endometrium using neuronal markers. MELISSA G. MEDINA, 2009

  29. A pilot study to evaluate the relative efficacy of endometrialbiopsy and full curettage in making a diagnosis ofendometriosis by the detection of endometrialnervefibers • Endometrial biopsies with precise, consistent technique andcurettings were taken from 37 women (20 with endometriosis and 17 withoutendometriosis). • Small nerve fibers were detected in allendometrial biopsiesand curettings from all 20 women with endometriosis, but were notdetected in endometrium taken from 17 women without endometriosis Moamar Al-Jefout, 2007

  30. Diagnosis of endometriosisbydetection of nerve fibres in anendometrialbiopsy: a doubleblindstudy M. Al-Jefout1, 2009

  31. Density of small diameter sensorynervefibres in endometrium: a semi-invasivediagnostic test for minimal tomildendometriosis • Secretory phase endometrium samples (n 40), obtained from women with laparoscopically/histologicallyconfirmed minimal–mild endometriosis (n 20) and from women with a normal pelvis (n 20) were selected • The density of small nerve fibres was 14 times higher in endometrium from patients with minimal–mild endometriosis(1.96+2.73) when compared with women with a normal pelvis (0.14+0.46, P , 0.0001). • The combined analysis of neural markers PGP9.5, VIP and SP could predict the presence of minimal–mildendometriosiswith 95% sensitivity, 100% specificity and 97.5% accuracy. A. Bokor, 2009

  32. Rich innervation of deep infiltratingendometriosis • DIE (n 31) and peritoneal endometriotic (n 40) lesions were sectioned • There were significantly more nerve fibres in DIE (67.6+65.1/mm2) than in peritoneal endometriotic lesions (16.3+10.0/mm2) (P , 0.01). GuoyunWang, 2009

  33. A pilot study to evaluate the clinical relevance ofendometriosis-associatednervefibers in peritonealendometrioticlesions SylviaMechsner, 2009

  34. Nervefibres in ovarianendometrioticlesions in women with ovarianendometriosis • Histological sections of ovarian endometriotic lesions from 61 women with ovarian endometriosis (Stages II–IV) who underwentlaparoscopicendometrioma • Nerve fibres stained with PGP9.5 were detected in ovarian endometriotic lesions in 31.1% of women, and most appeared in fibrotic interstitium of ovarian endometriotic lesions. The density of PGP9.5-immunoactive fibres in ovarian endometriotic lesions in womenwith pain symptoms (n 35) was higher than in women with no pain symptoms (n 26, P 0.039), although the percentage (positive cases/total) of PGP9.5-positive fibres did not differcystectomy XinmeiZhang, 2010

  35. Effect of progestogens and combined oralcontraceptives on nerve fibers in peritonealendometriosis • Biopsy samples from peritoneal endometriotic lesions in hormonally treated and untreatedwomenwithendometriosis. (N: 22 vs. N:40) • The nerve fiber density (mean standard deviation/mm2) in peritoneal endometriotic lesions from hormone-treated women with endometriosis (10.6 2.2/mm2) wasstatistically significantly lower than in peritonealendometriotic lesions from untreated women with endometriosis (16.3 10.0/mm2). • Progestogens and combined oral contraceptives reduced nerve fiber density and nerve growth factorand nerve growth factor receptor p75 expression in peritoneal endometriotic lesions. NatsukoTokushige, 2009

  36. Endometrial nerve fibers in women withendometriosis, adenomyosis, anduterinefibroids • To determine whether nerve fibers in the functional layer endometrium are caused by an endometriosis itself ora common symptom of pain, endometrial tissues from 30 women with endometriosis, 40 women with adenomyosis,41 women with uterine fibroids, and 47 endometriosis women with adenomyosis were stained immunohistochemicallyusing the highly specific polyclonal rabbit antiprotein gene product 9.5 (PGP9.5) and monoclonalmouse antineurofilament protein. • We demonstrated PGP9.5-immunoactive nerve fibers in the functional layerof endometrium in women with pain symptoms, but not in women without pain symptoms, whether the womenhad endometriosis, adenomyosis, uterine fibroids, or endometriosis with adenomyosis, suggesting a role ofPGP9.5-immunoactive nerve fibers in the functional layer of the endometrium playing in pain generation in thesedisorders XinmeiZhang, 2009

  37. Diagnostic accuracy of transvaginalsonographyfor the diagnosis ofadenomyosis: systematicreviewandmetaanalysis Susanna M. Meredith, 2009

  38. 2009 To develop a clinical tool that predicts pregnancy rates (PRs) in patients with surgically documented endometriosis who attempt non-IVF conception.

  39. Decreased anti-Mullerian hormone and altered ovarianfollicular cohort in infertile patients with mild/minimalendometriosis p:0.004 N:17 N:17 EE CC NadianeAlbuquerqueLemos, 2009

  40. Anti mullerianhormone serum levels in women with endometriosis:A case–controlstudy • 909 patients undergoing in vitro fertilisation/intracytoplasmic sperm injection(IVF/ICSI) treatment or consulting our specific endometriosis unit. • Mean AMH serum level was significantly lower in the study than in the control group (2.75+2.0 ng/ml vs.3.46+2.30 ng/ml, p0.001). • In women with mild endometriosis (rAFS I-II), the mean AMH level was almost equal to thecontrol group (3.28+1.93 ng/ml vs. 3.44+2.06 ng/ml; p0.61). • A significant difference in mean AMH serum level wasfound between women with severe endometriosis (rAFS III-IV) and the control group (2.38+1.83 ng/ml vs. 3.58+2.46 ng/ml; p 0.0001). OMAR SHEBL, 2009

  41. Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization Benny Almog, 2010

  42. The impact of electrocoagulation on ovarian reserveafter laparoscopic excision of ovarian cysts:a prospective clinical study of 191 patients • 191 patients with benign ovarian cysts undergoing ovarian cystectomy. • When comparing the bipolar group and ultrasonic scalpel group with the suture group, a statisticallysignificant increase of the mean FSH value was found in bilateral-cyst patients at 1-, 3-, 6-, and 12-month follow-up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation. • Statistically significant decreasesof basal antral follicle number and mean ovarian diameter were found during the 3-, 6-, 12-month follow-upevaluations as well as statistically significant decreases of peak systolic velocity at all of the follow-up evaluations. • Conclusion(s): Electrocoagulation after laparoscopic excision of ovarian cysts is associated with a statistically significantreduction in ovarian reserve, which is partly a consequence of the damage to the ovarian vascular system. Chang-ZhongLi, 2009

  43. A comparison of histopathologic findings of ovariantissue inadvertently excised with endometrioma andother kinds of benign ovarian cyst in patientsundergoinglaparoscopyversuslaparotomy SaeedAlborzi, 2009

  44. Analysis of risk factors for the removalof normal ovarian tissue duringlaparoscopiccystectomyforovarianendometriosis • A total of 121 patients who had histologically confirmed ovarian endometriosis and 56 control patients who had other histologicallyconfirmed benign cysts were included • Normal ovarian tissue adjacent to the cyst wall was detected in 71 patients (58.7%) with endometriosis, whereas normalovarian tissue was removed from only three patients (5.4%) with other benign cysts. • A significant factor that was independently associatedwith the removal of normal ovarian tissue with ovarian endometriosis was pre-operative medical treatment SachikoMatsuzaki1,2009

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