Endometriosis

Assoc. Prof. Gazi YILDIRIM, M.D.

Yeditepe University, Medical Faculty Dept of Ob&Gyn

To discover ◦ Endometriosis◦ Endometriosis related condition

To learn◦ Diagnosis of endometriosis◦ Treatment of endometriosis

Objectives

Definition: Ectopic Endometrial Tissue

True Incidence Unknown: ? 1-5%

Histology: Endometrial Glands with Stroma +/- Inflammatory

Reaction

Endometriosis

Prevalence

Surgical Series (Uncontrolled) 1 – 53%

Surgical Series (Controlled) 23 – 47% (Infertile) 1 – 5% (Fertile)

Population-Based Studies 6.2 –7.9%

Epidemiological Study 0.25 new cases/1000 woman-years

Prevalence = 7.5% Endometriosis Affects ~5

Million Women, 30-40% are Infertile

Surgical Series (Uncontrolled) 1 – 53%

Surgical Series (Controlled) 23 – 47% (Infertile)1 – 5% (Fertile)

Population-Based Studies 6.2 –7.9%

Epidemiological Study 0.25 new cases/1000w oman-years

Prevalence = 7.5%Endometriosis Affects ~5

Million W omen, 30-40%are Infertile

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

Signs and Symptoms

Uterine= Adenomyosis (50%).

Extraut:- Ovary 30%- Pelvic peritoneum 10%.- F. tube.- Vagina.-Bladder & rectum.- Pelvic colon.- Ligaments.

Pelvic Endometriosis

Age at Diagnosis

< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%

Sampson: “Retrograde Menstruation” Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the AboveNo Single Theory Explains All Cases of

Endometriosis

Etiology: Theories

Diagnosis of Endometriosis

History (The most important) Symptoms Physical Examination (not much help) Serum Markers (Lacks sensitivity) Ultrasound (of little value except endometrioma) Magnetic Resonance Imaging (MRI) (a good guess!) Other Imaging Modalities

◦ immunoscintigraphy and positron emission tomography Transvaginal Hydrolaparoscopy Laparoscopic Visualization of the Pelvis (The gold

standard)◦ Biopsy Preferable Over Visual Inspection

Novel Diagnostic Test

Rule out other Causes of Symptoms (The next most important)

Laparoscopy (“Gold Standard)

Laparotomy

Inconclusive: CA-125, CA-199Pelvic Exam,

History, Imaging Studies

Biopsy Preferable Over Visual Inspection

Diagnosis

Endometriosis May AppearBrownBlack (“Powderburn”)Clear (“Atypical”)

Endometriosis May Be Associated with Peritoneal Windows

Appearance

ENDOMETRIOSIS AND ADOLESCENCE

Variety of endometriotic lesions seen at laparoscopy

Endometriosis-Peritoneal

0varian endometriosis

ENDOMETRIOSIS AND ADOLESCENCE

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.

Revised AFS 1985

Stage I (minimal) 1 – 5Stage II (mild) 6 – 15Stage III (moderate) 16 – 40

Stage IV (severe) > 40

Endometriozis-Evreleme

EVRE-1 (minimal= 1-5) EVRE-2 (hafif = 6-15)

EVRE-3 (orta = 16-40) EVRE-4 (ağır = > 40)

Recognize Goals: – Pain Management– Preservation / Restoration of Fertility

Discuss with Patient:– Disease may be Chronic and Not Curable– Optimal Treatment Unproven or

Nonexistent

Treatment: Overall Approach

NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Misc: Opoids, TCAs, SSRIs

Pain Management: Medical Therapy

“Pseudopregnancy” (Kistner) ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical

Treatments Choose OCPs with Least Estrogenic Effects,

Maximal Androgenic / Progestin Effects

Continuous OCPs

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

Progestins

Weak Androgen Suppresses LH / FSH Causes Endometrial Regression, Atrophy Expensive Side-Effects: Weight Gain, Masculinization,

Occ. Permanent Vocal Changes

Danazol

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 )

GnRH-a

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

Surgical Treatment (Laparoscopy / Laparotomy)