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Endometriosis

Endometriosis. Dr.Mona Shroff M.D. Endometriosis. Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% Does NOT Discriminate by Race Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction. Sites. - Pelvic - Extra pelvic Umbilicus. Scars (Lap.).

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Endometriosis

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  1. Endometriosis Dr.MonaShroff M.D

  2. Endometriosis • Definition: Ectopic Endometrial Tissue • True Incidence Unknown: ? 1-5% • Does NOT Discriminate by Race • Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

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

  4. Pelvic Endometriosis • Uterine= Adenomyosis (50%). • Extraut: - Ovary 30% - Pelvic peritoneum 10%. - F. tube. - Vagina. -Bladder & rectum. - Pelvic colon. - Ligaments.

  5. Prevalence

  6. Age at Diagnosis > 45 < 19 3% 36 –45 6% 15% 19 – 25 24% 26 –35 52%

  7. Signs and Symptoms • Chronic Pelvic Pain, Dysmenorrhea • Abnormal Uterine Bleeding • Infertility • Deep Dyspareunia • Pelvic Mass (Endometrioma) • Misc: Tenesmus, Hematuria, Hemoptysis

  8. Signs Pelvic examination may reveal: 1. Pelvic tenderness. 2. Fixed retroverted uterus. 3. Nodularity of the Douglas pouch and uterosacral ligaments. 4. Ovaries may be enlarged and tender . Ovarian cyst may be detected.

  9. 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

  10. Diagnosis • Laparoscopy (“Gold Standard) • Laparotomy • Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies • Biopsy Preferable Over Visual Inspection

  11. Appearance Endometriosis May Appear • Brown • Black (“Powderburn”) • Clear (“Atypical”) Endometriosis May Be Associated with Peritoneal Windows

  12. 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

  13. Treatment : Consideration • Age. • Symptoms. • Stage. • Infertility.

  14. 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

  15. Pain Management: Medical Therapy • NSAIDs • OCPs (Continuous) • Progestins • Danazol • GnRH-a • GnRH-a + Add-Back Therapy • Misc: Opoids, SSRIs

  16. 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.

  17. 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 .

  18. Aim of the hormonal therapy cont…. (B) Pseudomenopause (induction of amenorrhoea) by: 1. Danazol. 2. Gn RH analogues. 3. Gestrinone. 4. Gossypol.

  19. Continuous OCPs • “Pseudopregnancy” (Kistner) • ? Minimizes Retrograde Menstruation • Lower Fertility Rates than Other Medical Treatments • Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects

  20. 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

  21. Danazol • Weak Androgen • Suppresses LH / FSH • Causes Endometrial Regression, Atrophy • Expensive • Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes

  22. GnRH-a (Leuprolide,triptorelin) • 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 )

  23. 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 . • 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 .

  24. Surgical Treatment (Laparoscopy / Laparotomy) • Excision / Fulgration(ELECTROCAUTRY/LASER) • Resection of Endometrioma • Lysis of Adhesions, Cul-de-sac Reconstruction • Uterosacral Nerve Ablation • Presacral Neurectomy • Appendectomy • Uterine Suspension (? Efficacy) • Hysterectomy +/- BSO

  25. 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

  26. 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

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