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ENDOMETRIOSIS AND MANAGEMENT OPTIONS

ENDOMETRIOSIS AND MANAGEMENT OPTIONS. INTRODUCTION. ENDOMTRIOSIS IS ONE OF THE COMMONEST DISEASE ENTITIES CONFRONTING GYNAECOLOGISTS. IT IS THOUGHT TO AFFECT 8-10% OF WOMEN IN THE REPRODUCTIVE AGE GROUP

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ENDOMETRIOSIS AND MANAGEMENT OPTIONS

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  1. ENDOMETRIOSIS AND MANAGEMENT OPTIONS

  2. INTRODUCTION • ENDOMTRIOSIS IS ONE OF THE COMMONEST DISEASE ENTITIES CONFRONTING GYNAECOLOGISTS. • IT IS THOUGHT TO AFFECT 8-10% OF WOMEN IN THE REPRODUCTIVE AGE GROUP • 20-50% OF WOMEN WHO UNDERGO LAPAROSCOPY FOR PELVIC PAIN OR INFERTILITY WILL BE DIAGNOSED WITH ENDOMETRIOSIS • I T IS STILL HOWEVER A FAIRLY UNKNOWN ILLNESS OFTEN TAKING A LONG TIME BEFORE IT IS DIAGNOSED.

  3. INTRODUCTION CONT’D • THERE CAN BE A DELAY OF BETWEEN 7-10 YEARS BETWEEN ONSET OF SYMPTOMS AND DIAGNOSIS. • THE ASSOCIATED SYMPTOMS CAN IMPACT ON GENERAL PHYSICAL, MENTAL AND SOCIAL WELLBEING. • APPARENTLY INCREASING INCIDENCE MAY BE AS A RESULT OF INCREASED AWARENESS, AVAILABILITY OF LAPAROSCOPY AND RECENT RECOGNITION OF SUBTLE LESIONS.

  4. DEFINITION • THE PRESENCE AND PROLIFERATION OF FUNCTIONAL ENDOMETRIAL GLANDS AND STROMA OUTSIDE THE UTERINE CAVITY, WHICH INDUCES A CHRONIC INFLAMMATORY REACTION.

  5. CLASSIFICATION • SEVERAL SYSTEMS EXIST TO CLASSIFY ENDOMETRIOSIS. • THE COMMONEST IS THAT FROM THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE.(ASRM). • IN THIS, POINTS ARE ALLOCATED FOR -ENDOMETRIOTIC LESIONS, -PERIOVARIAN ADHESIONS,AND – POUCH OF DOUGLAS OBLITERATION. THE TOTAL SCORE IS USED TO DESCRIBE THE DISEASE AS

  6. CLASSIFICATION CONTD • MINIMAL OR STAGE 1 • MILD OR STAGE 2 • MODERATE OR STAGE 3 • SEVERE OR STAGE 4 • THIS SYSTEM WAS DEVELOPED TO ASSIST IN PROGNOSIS AND MANAGEMENT OF PATIENTS UNDERGOING TREATMENT FOR SUBFERTILITY, AND DOES NOT CORRELATE WELL WITH SYMPTOMS ……

  7. CLASSIFICATION CONTD • BECAUSE ONLY VISIBLE LESIONS ARE GRADED, DEEPLY INFILTRARING ENDOMETRIOSIS, A MAJOR CAUSE OF PELVIC PAIN AND DYSPAREUNIA IS TYPICALLY ASSIGNED A LOW SCORE. • A BETTER METHOD IS THEREFORE CLEARLY REQUIRED.

  8. AETIOLOGY • DISEASE OF THEORIES. • NONE OF THE THEORIES SATISFACTORILY EXPLAINS ALL ASPECTS OF THE DISEASE. • IT MAY ACTUALLY BE THAT ENDOMETRIOSIS IS A HETEROGENOUS DISEASE WITH DIFFERENT TYPES RESULTING FROM DIFFERENT AETIOLOGIES.

  9. AETIOLOGY CONTD • RETROGRADE MENSTRUATION (SAMPSON1927) • MENSTRUAL EFFLUENT CONTAINING VIABLE CELLS IS TRANSPORTED INTO THE PERITONEAL CAVITY ALONG THE FALLOPIAN TUBES AND IMPLANTS ON THE SURFACE OF THE PERITONEUM. IT MAY EXPLAIN PERITONEAL ENDOMETRIOSIS. IT HOWEVER DOES NOT EXPLAIN WHY THOUGH RETROGRADE MENSTRUATION IS COMMON, THE DISEASE OCCURS IN = 10%

  10. AETIOLOGY CONTD • THE AMOUNT OF MENSTRUAL EFFLUENT (OBSTRUCTED OUTFLOW ASSOCIATED WITH MULLERIAN ANOMALIES AND SHORTER MENSTRUAL CYCLES WITH INCREASED DURATION OF BLEEDING) • DEFECTS IN IMMUNOLOGICAL MECHANISMS RESPONSIBLE FOR CLEARANCE OF MENSTRUAL EFFLUENT FROM PERITONEAL CAVITY MAY EXPLAIN THE DIFFERENT SUSCEPTIBILITY. WOMEN WITH ENDOMETRIOSIS HAVE A HIGHER INCIDENCE OF AUTOIMMUNE DISEASES LIKE RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERYTHEMATOSUS.

  11. AETIOLOGY CONTD • COELOMIC-METAPLASIA THEORY ENDOMETRIOTIC LESIONS DEVELOP WHEN COELOMIC MESOTHELIAL CELLS OF THE PERITONEUM UNDERGO METAPLASIA. • MAY EXPLAIN ENDOMETRIOMAS AND DEEPLY INFILTRATING ENDOMETRIOSIS (DIE).

  12. AETIOLOGY CONTD • ENDOMETRIOMAS HAVE FEATURES IN COMMON WITH NEOPLASIA SUCH AS CLONAL PROLIFERATION AND MANY ARE ASSOCIATED WITH SUBTYPES OF OVARIAN MALIGNANCY SUCH AS ENDOMETRIOID AND CLEAR CELL CARCINOMA. • ENDOMETRIOMAS HAVE HOWEVER ALSO BEEN SUGGESTED TO DEVELOP WHEN SUPERFICIAL LESIONS ON OVARIAN CORTEX BECOME INVERTED AND INVAGINATED

  13. AETIOLOGY CONTD • DEEPLY INFILTRATING ENDOMETRIOSIS HAS BEEN DESCRIBED AS A FORM OF ADENOMYOSIS ARISING IN MULLERIAN RESTS IN THE RECTOVAGINAL SEPTUM. • ANOTHER THEORY POSTULATES THE CIRCULATION AND IMPLANTATION OF ECTOPIC MENSTRUAL TISSUE VIA THE VENOUS OR THE LYMPHATIC SYSTEM, OR BOTH.

  14. TYPES OF LESIONS • PERITONEAL ENDOMETRIOSIS • TYPICAL • SUPERFICIAL “POWDER-BURN” OR “GUNSHOT” LESIONS ON PERITONEAL SURFACES AND OVARIES>>>>BLACK, BLUE , DARK BROWN. • ATYPICAL • RED(PETECHIAL,VESICULAR,POLYPOID,HAEMORRHAGIC, FLAME-LIKE), YELLOW-BROWN PERITONEAL DISCOLOURATION, SEROUS OR CLEAR, WHITE PLAQUES.

  15. TYPES OF LESIONS • ENDOMETRIOMAS • THESE CONTAIN THICK FLUID’ LIKE TAR. THEY MAY BE DENSELY ADHERENT TO PERITONEUM OF OVARIAN FOSSA AND SURROUNDING FIBROSIS MAY INVOLVE TUBES AND BOWEL. • DEEPLY INFILTRATING ENDOMETRIOSIS (DIE) • NODULAR DISEASE WHICH MAY EXTEND BEYOND 5MM BENEATH THE PERITONEUM. MAY INVOLVE UTEROSACRAL LIGAMENTS, VAGINA, BOWEL, BLADDER OR UTERUS. TYPE AND SEVERITY OF SYMPTOMS IS RELATED TO DEPTH OF INFILTRATION .

  16. RISK FACTORS • AGE • INCREASED PERIPHERAL BODY FAT • GREATER EXPOSURE TO MENSTRUATION(EARLY MENARCHE, SHORT CYCLES, LONG DURATION OF FLOW,NULLIPARITY OR LOW PARITY, REPRODUCTIVE TRACT ANOMALIES). • SUBFERTILITY OR PROLONGED INTERVALS BETWEEN PREGNANCIES.

  17. RISK FACTORS CONTD • GENETIC PREDISPOSITION (IT OCCURS 6-9 TIMES MORE IN FIRST DEGREE RELATIVES OF AFFECTED WOMEN THAN IN CONTROLS) • IT MAY BE INHERITED AS A COMPLEX GENETIC TRAIT LIKE ASTHMA OR DIABETES(PHENOTYPE EMERGING ONLY IN THE PRESENCE OF ENVIRONMENTAL RISK FACTORS). • STUDIES HAVE SHOWN A SIGNIFICANT SUSCEPTIBILTY LOCUS FOR ENDOMETRIOSIS ON CHROMOSOME 10q26 AND ANOTHER ON CHROMOSOME 20p13.

  18. PROTECTIVE FACTORS • SMOKING. • EXERCISE. • ORAL CONTRACEPTIVE USE. • LONG OR IRREGULAR CYCLES. • INCREASED PARITY.

  19. SYMPTOMS • SEVERE DYSMENORRHEA • DEEP DYSPAREUNIA • CHRONIC PELVIC PAIN (NON CYCLICAL ABDOMINAL AND PELVIC PAIN OF AT LEAST 6MONTHS DURATION) • OVULATION PAIN • CYCLICAL PERIMENSTRUAL SYMPTOMS…BOWEL RELATED(DYSCHEZIA, HAEMATOCHEZIA)…BLADDER RELATED(DYSURIA, HAEMATURIA) • LOWER BACK OR ABDOMINAL DISCOMFORT • CHRONIC FATIGUE

  20. SYMPTOMS CONTD • THE PREDICTIVE VALUE OF ANY ONE SYMPTOM OR SET OF SYMPTOMS IS UNCERTAIN SINCE EACH CAN HAVE OTHER CAUSES. • MANY WOMEN ARE ASYMPTOMATIC • WHERE AS THERE IS LITTLE CORRELATION BETWEEN DISEASE STAGE,NATURE AND SEVERITY OF SYMPTOMS, ENDOMETRIOMAS AND DIE ARE CLEARLY ASSOCIATED WITH SEVERE PAIN. TYPICAL PERITONEAL LESIONS PROBABLY CAUSE PAIN AS SYMPTOMS ARE RELIEVED BY SURGERY. IT IS UNCLEAR IF THIS APPLIES TO SUBTLE LESIONS.

  21. SIGNS • PELVIC TENDERNESS • A FIXED RETROVERTED UTERUS • TENDER/ NODULAR UTEROSACRAL LIGAMENTS (POSTERIOR FORNIX/POD) • ENLARGED OVARIES (ADNEXEAL MASSES)

  22. DIAGNOSIS HISTORY • DETAILED PAIN AND GYNAE HISTORY • -EXPLORE OTHER CAUSES OF PAIN • -AGE AT MENARCHE • -CYCLE FREQUENCY AND REGULARITY • -PREVIOUS PREGNANCIES • -USE OF COCPS AND HORMONAL TX • -FAMILY HX OF ENDOMETRIOSIS AND GYNAECOLOGICAL CANCERS. • -REMEMBER SYMPTOMS MAY HAVE OTHER CAUSES.

  23. EXAMINATION • THIS IS ESSENTIAL FOR DIAGNOSIS, DETERMINE APPROPRIATE CARE AND RULE OUT OTHER DISORDERS. EXAMINATION DURING MENSES INCREASES THE CHANCES OF DETECTING D I E. • - DETERMINE SIZE, POSITION AND MOBILITY OF UTERUS( A FIXED RETROVERTED UTERUS MAY SUGGEST SEVERE ADHESIVE DISEASE ) • -RECTOVAGINAL EXAM…PALPATE UTEROSACRAL LIGAMENTS ( TENDER NODULES SUGGEST D I E) • -ADNEXIAL MASSES MAY SUGGEST OVARIAN ENDOMETRIOMAS

  24. INVESTIGATIONS • -ULTRASOUND SCAN..TVUSS..USELESS IN PERITONEAL DISEASE BUT DETECTS ENDOMETRIOMAS, OVARIAN CYSTS AND FIBROIDS. TYPICAL APPEARANCE IS THAT OF A THICK WALLED UNILOCULAR CYST CONTAINING LOW LEVEL ECHOES. • -MRI..MAY BE USED IN EVALUATING EXTENT OF DISEASE..BLADDER, RECTAL, URETERIC INVOLVEMENT. • -CA 125.. MAY BE ELEVATED IN ENDOMETRIOSIS BUT NOT SPECIFIC. USEFUL IN EVALUATING ADNEXIAL MASSES(ENDOMETRIOMA)

  25. INVESTIGATIONS CONTD LAPAROSCOPY • EXCEPT FOR WHEN VISIBLE DISEASE IS PRESENT IN THE VAGINA OR ELSEWHERE, THIS IS CONSIDERED THE GOLD STANDARD FOR DIAGNOSTIC PURPOSES (DIRECT VISUALIZATION OF LESIONS/ ADHESIONS). • HISTOLOGICAL CONFIRMATION OF AT LEAST ONE PERITONEAL LESION IS IDEAL. HISTOLOGY IS MANDATORY IN D I E AND HELPS EXCLUDE MALIGNANCY IN ENDOMETRIOMAS > 3CM.

  26. INVESTIGATIONS CONTD • THE ENTIRE PELVIS SHOULD BE EXAMINED SYSTEMATICALLY. • STAGE DISEASE ACCORDING TO ASRM STAGING. • GOOD PRACTICE- DOCUMENT IN DETAIL, TYPE, LOCATION AND EXTENT OF ALL LESIONS AND ADHESIONS. • IDEAL- RECORD FINDINGS ELECTRONICALLY= DVD, VIDEO.

  27. DIFFERENTIAL DIAGNOSIS UTERINE- PRIMARY DYSMENORRHEA - ADENOMYOSIS BOWEL - IRRITABLE BOWEL SYNDROME -INFLAMMATORY BOWEL DISEASE -CHRONIC CONSTIPATION BLADDER - INTERSTITIAL CYSTITIS -URINARY TRACT INFECTION -URINARY TRACT CALCULI

  28. DIFFERENTIAL DIAGNOSIS OVARIAN - MITTELSCHMERZ (OVULATION PAIN) - OVARIAN CYSTS (TORSION, RUTURE, ETC) FALLOPIAN TUBES - HAEMATOSALPINX - ECTOPIC PREGNANCY GENERAL - NEUROPATHIC PAIN - ADHESIONS - PELVIC INFLAMMATORY DISEASE

  29. TREATMENT • MULTIPLE OPTIONS EXIST. ENDOMETRIOSIS IS A POTENTIALLY CHRONIC PROBLEM SO PATIENT PARTICIPATION IN DECISION MAKING IS ESSENTIAL. • CHOICE OF TREATMANT WILL DEPEND ON THE AIMS FOR TREATING.

  30. TREATMENT AIMS • TO IMPROVE NATURAL FERTILITY • TO ENHANCE CHANCES OF SUCCES AT ART • PAIN RELIEF AS ALTERNATIVE TO SURGERY. • PAIN RELIEF WHILE AWAITING SURGERY. • ADJUNCT TO SURGERY. • PROPHYLAXIS AGAINST DISEASE RECURRENCE.

  31. TREATMENT:GENERAL PRINCIPLES • FACTORS -AGE, SEVERITY OF SYMPTOMS/ DISEASE, DESIRE FOR PROCREATION. • E.G 40+YRS, DEBILITATING PAIN, SEVERE DISEASE, COMPLETED FAMILY= OFFER TAH+BSO, PROVIDED ALL ENDOMETRIOTIC TISSUE IS REMOVED AT THE SAME TIME.

  32. TREATMENT:GENERAL PRINCIPLES • YOUNG NULLIPAROUS WOMAN, WITH ABOVE PRESENTATION WILL WANT AS MUCH TISSUE CONSERVATION AS POSSIBLE IF SHE OPTS FOR SURGERY. • AGREE ON TREATMENT AIMS WITH PATIENT. SO FOR SURGERY=INTENDED BENEFITS, RISKS AND COMPLICATIONS SHOULD BE EXPLAINED AND DOCUMENTED ON CONSENT FORM.

  33. MEDICAL MANAGEMENT • HORMONAL TREATMENTS TRADITIONALLY HAVE ATTEMPTED TO MIMIC PREGNANCY OR THE MENOPAUSE BASED ON THE CLINICAL IMPRESSION THAT THE DISEASE REGRESSES DURING THESE PHYSIOLOGICAL STATES.

  34. MEDICAL MANAGEMENT • AVAILABLE OPTIONS TEND TO INDUCE DECIDUALIZATION AND ATROPHY OF PERITONEAL DEPOSITS BY SUPPRESSING OVARIAN FUNCTION. PERITONEAL LESIONS DECREASE DURING, ONLY TO REAPPEAR AFTER THERAPY. ENDOMETRIOMAS RARELY DECREASE IN SIZE AND ADHESIONS ARE UNAFFECTED.

  35. MEDICAL MANAGEMENT:PAIN • PRIOR LAPAROSCOPY MAY NOT BE REQUIRED BEFORE STARTING MEDICAL TREATMENT IN WOMEN WITH SEVERE DYSMENORRHEA OR CHRONIC PELVIC PAIN. • IF SEVERE DYSMENORRHEA IS UNRESPONSIVE TO NSAIDS, + PELVIC TENDERNESS, NODULARITY OR USS DIAGNOSES AN ENDOMETRIOMA THEN SUSPECT ENDOMETRIOSIS.

  36. MEDICAL MANAGEMENT:PAIN • ALL HORMONAL TREATMENTS RELIEVE ENDOMETRIOSIS ASSOCIATED PAIN, AND CAN ABOLISH MENSTRUATION. TAKEN FOR SIX MONTHS, THEIR EFFECTS ARE ALMOST EQUAL BUT SIDE EFFECTS PROFILES AND COSTS DIFFER.

  37. MEDICAL MANAGEMENT:PAIN • FIRST LINE= COCP . THERE IS SIGNIFICANT RELIEF IN MENSES RELATED PAIN BUT NONE IN NON MENSTRUAL PAIN(? CONTINUOUS VS CYCLICAL). • SECOND LINE (AFTER COCP OR PROGESTOGENS)=GnRH AGONISTS

  38. MEDICAL MANAGEMENT • NSAIDS • THERE ARE FOUR BROAD TYPES OF HORMONE-BASED TREATMENT: • PROGESTOGENS • ANTIPROGESTOGENS • THE COMBINED ORAL CONTRACEPTIVE PILL • GONADOTROPHIN-RELEASING HORMONE (GNRH) ANALOGUES

  39. MEDICAL MANAGEMENT:PROGESTOGENS • DEPOT MEDROXY PROGESTERONE ACETATE • NORETHISTERONE • DYDROGESTERONE • LNG-IUS (MIRENA) • DIRECT EFFECT ON ENDOMETRIUM= MARKED DECIDUALIZATION AND ATROPHY OF BOTH EUTOPIC AND ECTOPIC ENDOMETRIUM . ALSO SUPPRESSION OF HPO AXIS. ALSO INHIBIT ANGIOGENESIS. • DRAW BACK=NON CYCLIC PELVIC PAIN NOT SIGNIFICANTLY REDUCED.

  40. MEDICAL MANAGEMENT:ANTI PROGESTOGENS • DANAZOL • GESTRINONE • ALSO ANDROGENIC. INDUCE AMENORRHEA VIA SUPPRESSION OF HPO AXIS…INCREASED SERUM ANDROGENS AND LOW SERUM OESTROGEN LEVELS. • EFFECTIVE • DRAW BACK=WT GAIN, OEDEMA, MYALGIA, ACNE, HIRSUITISM, BREAST ATROPHY

  41. MEDICAL MANAGEMENT: COMBINED ORAL CONTRACEPTIVE PILL • RESULT IN OVULATION INHIBITION, REDUCED MENSTRUAL FLOW AND DECIDUALIZATION OF ENDOMETRIAL IMPLANTS. • OESTROGEN COMPONENT MAY BE A DRAW BACK. • CYCLIC USE PERMITS MENSTRUATION SO DYSMENORRHEA STILL OCCURS + POSSIBLE RETROGRADE FLOW

  42. MEDICAL MANAGEMENT : GONADOTROPHIN RELEASING HORMONE ANALOGUES • AMONG MOST WIDELY USED MEDICAL THERAPIES. • INDUCE MEDICAL MENOPAUSE BY DOWN REGULATING HYP-PIT GnRH RECEPTORS>>SUPPRESS OVULATION, DECREASE OESTROGEN LEVELS. • DRAW BACKS=HYPOESTROGENIC S-E >>HOT FLUSHES, VAGINAL DRYNESS, LOSS OF LIBIDO, EMOTIONAL LABILITY, LOSS OF BONE MINERAL DENSITY. • RECENTLY USE OF ‘ADD BACK ‘ REGIMES >>HRT TO MAKE IT POSSIBLE TO USE TX LONG TERM.

  43. MEDICAL MANAGEMENT: SUBFERTILITY • HORMONAL TREATMENT IN THE FORM OF OVARIAN SUPPRESSION DOES NOT IMPROVE CHANCES OF NATURAL CONCEPTION IN MINIMAL TO MILD DISEASE. HARMFUL. • ART: CONTROLLED OVARIAN HYPERSTIMULATION COMBINED WITH INTRAUTERINE INSEMINATION (IUI) IMPROVES FERTILITY IN ENDOMETRIOSIS.

  44. MEDICAL MANAGEMENT:SUBFERTILITY • IVF: PATIENTS OVER 35YEARS SHOULD BE COUNSELLED FOR IVF. PREGNANCY RATES ARE LOWER THAN IN WOMEN WITH OTHER DIAGNOSES. PATIENTS WITH CHRONIC OR ADVANCED ENDOMETRIOSIS MAY BENEFIT FROM LONG TERM (3-6MONTHS) TREATMENT WITH A GnRH AGONIST BEFORE AN IVF CYCLE.

  45. SURGERY :INDICATIONS • PATIENTS WITH PELVIC PAIN -WHO DO NOT RESPOND TO, DECLINE OR HAVE CONTRA-INDICATIONS TO MEDICAL THERAPY. -WHO HAVE AN ACUTE ADNEXIAL EVENT -WHO HAVE SEVERE INVASIVE DISEASE INVOLVING BOWEL, BLADDER, URETERS OR PELVIC NERVES.

  46. SURGERY: INDICATIONS • PATIENTS WHO HAVE OR ARE SUSPECTED TO HAVE AN OVARIAN ENDOMETRIOMA -PATIENTS WITH INFERTILITY AND ASSOCIATED FACTORS…PAIN, A PELVIC MASS. -PATIENTS FOR WHOM AN UNCERTAINTY OF DIAGNOSIS AFFECTS MANAGEMENT(AS WITH CHRONIC PELVIC PAIN).

  47. SURGERY:GOAL • TO REMOVE ALL VISIBLE PERITONEAL LESIONS, ENDOMETRIOMAS, D I E AND ASSOCIATED ADHESIONS AND RESTORE NORMAL ANATOMY AND OPTIMIZE OVARIAN AND TUBAL PRESERVATION. • SINCE DEPTH OF INFILTRATION IS DIFFICULT TO JUDGE, EXCISION OR VAPORIZATION IS PREFERABLE FOR TYPICAL LESIONS. EXCISION IS PREFERRED FOR ENDOMETRIOMAS AS RECURRENCE RATES ARE HIGHER FOLLOWING MARSUPIALIZATION.

  48. SURGERY: METHOD • LAPAROSCOPY IS PREFERRED. -DECREASES MORBIDITY AND DURATION OF HOSPITALIZATION AND THEREFORE COST. -LESS ADHESIOGENIC -IF LOCAL EXPERTISE IS LACKING REFERRAL TO A SPECIALIZED CENTRE WITH NECESSARY EXPERTISE TO OFFER ALL AVAILABLE TREATMENT IN A MULTIDISCIPLINARY CONTEXT IS STRONGLY RECOMMENDED.

  49. SURGERY: METHOD • PRINCIPLES OF MICROSURGERY VIZ DILIGENT HAEMOSTASIS, REDUCED FULGURATION , AVOIDANCE OF TISSUE DRYING AND LIMITED USE OF SUTURES MAKE LAPAROSCOPY ADVANTAGEOUS.

  50. SURGERY:PAIN RELIEF • ABLATION OF LESIONS IN MINIMAL TO MODERATE DISEASE REDUCES PAIN AT 6 MONTHS. LUNA( LAPAROSCOPIC UTERINE NERVE ABLATION) HAS NOT BEEN PROVEN TO BE NECESSARY SINCE BY ITSELF NO EFFECT HAS BEEN NOTED. • IN D I E AND ENDOMETRIOMAS, STUDIES HAVE SHOWN 80% OF WOMEN WITH SEVERE SYMPTOMS ARE PAIN FREE FOLLOWING SURGERY.

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