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ENDOMETRIOSIS

ENDOMETRIOSIS. WHAT IS THE GENERAL PRACTICE APPROACH?. FIRST – A FEW QUESTIONS!. IS TREATMENT ALWAYS REQUIRED? WHO NEEDS TREATMENT? DOES ANY TREATMENT REALLY WORK? DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?. I DON’T HAVE THE ANSWERS.

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ENDOMETRIOSIS

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  1. ENDOMETRIOSIS WHAT IS THE GENERAL PRACTICE APPROACH?

  2. FIRST – A FEW QUESTIONS! • IS TREATMENT ALWAYS REQUIRED? • WHO NEEDS TREATMENT? • DOES ANY TREATMENT REALLY WORK? • DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?

  3. I DON’T HAVE THE ANSWERS • ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE • SPON REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES • NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

  4. HOWEVER---- • MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD • COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP • PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSIS—PERSISTENCE, REGRESSION AND PROGRESSION

  5. AND ALSO--------- • ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT • LAPAROSCOPIC ABLATION OF VISIBLE ENDO IN INFERTILE WOMEN IS ASSOC WITH SIGNIFICANTLY INCREASED FERTILITY RATES • THERE IS NO DATA REGARDING EARLY INTERVENTION WRT PREVENTION

  6. PREVALENCE • NOT PRECISELY KNOWN—2-5% • 20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMEN • BUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION • 52% OF TEENAGES WITH CPP SYNDROME

  7. Familial association • Relative Risk to siblings 2.3 overall • Relative Risk to sibs if severe endo 15

  8. Risk factors • Single/nulliparous • Early menarche • Non oral contraception • Non smoker shorter cycle/longer duration of flow • Dysplastic naevus syndrome, melanoma

  9. symptoms • 90% severe dysmenorrohoea • 70% chronic pelvic pain • 75% dyspareunia • 55% infertility

  10. Infertility mechanisms

  11. Treatment of pain • NSAIDS: all significantly better than placebo, studies vary which one is best • Naproxen >mefanemic acid>aspirin • Naproxen=ibuprofen • Naproxen only drug with significant SEs

  12. treatment of menstrual pain Treatment level of evidence Simple analgesics 1 Herbal remedies 1 alcohol 2 Antidepressants/anxiolytics 2 OCPs 1 NSAIDS 3

  13. ENDOMETRIOSIS PAIN • PSYCO-PHYSICAL TREATMENTS-ACCUPUNCTURE, MESSAGE, RELAXATION, TENS • EXERCISE • ANTI-OESTROGEN DRUGS • LAPAROSCOPY/ OPEN SURGERY

  14. LIMITATIONS OF DRUG THERAPY • ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITE • SHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASE • RESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENT • DOES NOT DEAL WITH ADHESIONS

  15. META-ANALYSIS MIN/MILD ENDOMETRIOSIS

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