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Endometriosis

Endometriosis. Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn. Endometriosis. Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction. Prevalence. Signs and Symptoms.

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Endometriosis

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  1. Endometriosis Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn

  2. Endometriosis • Definition: Ectopic Endometrial Tissue • True Incidence Unknown: ? 1-5% • Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

  3. Prevalence

  4. Signs and Symptoms • Asymptomatic. • Pain (DYS…….): - Dysmenorrhea (crescendo = progessive) - Dyspareunia. - Dyschesia. - Dysuria. • Chronic Pelvic Pain • Backache. • Acute abdomen. • Premenst. Tension syndrome. • Abnormal Uterine Bleeding • Infertility • Pelvic Mass (Endometrioma) • Misc: Tenesmus, Hematuria,Hemoptysis

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

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

  7. 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

  8. 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)

  9. Diagnosis • Laparoscopy (“Gold Standard) • Laparotomy • Inconclusive: CA-125, CA-199Pelvic Exam, History, Imaging Studies • Biopsy Preferable Over Visual Inspection

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

  11. ENDOMETRIOSIS AND ADOLESCENCE Variety of endometriotic lesions seen at laparoscopy

  12. Endometriosis-Peritoneal

  13. ENDOMETRIOSIS AND ADOLESCENCE 0varian endometriosis

  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. Revised AFS 1985 • Stage I (minimal) 1 – 5 • Stage II (mild) 6 – 15 • Stage III (moderate) 16 – 40 • Stage IV (severe) > 40

  16. Endometriozis-Evreleme EVRE-1 (minimal= 1-5) EVRE-2 (hafif = 6-15) EVRE-3 (orta = 16-40) EVRE-4 (ağır = > 40)

  17. 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

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

  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 • 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. Surgical Treatment (Laparoscopy / Laparotomy) • Excision Yes/ Fulgeration No! • Resection of Endometrioma • Lysis of Adhesions, Cul-de-sac Reconstruction • Uterosacral Nerve Ablation • Presacral Neurectomy • Appendectomy • Uterine Suspension (? Efficacy) • Hysterectomy +/- BSO

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