Endometriose: Que doit savoir

le Gastro - Entérologue ?

Université Paris Descartes,

Sorbonne Paris Cité

Faculté de Médecine, AP-HP,

GHU Ouest, CHU Cochin, Paris, France

Professor Charles Chapron, M.D Head of Department,

Gynecology

Surgical unit: C Chapron, B Borghese, P Santulli,

H Foulot, MC Lafay-Pillet, A Bourret,

G Pierre, A Bititi, P Marzouk, L Marcellin

Medical unit: A Gompel, G Plu-Bureau, L Maitrot

Reproductive Endocrinology unit: D de Ziegler, P Santulli, V Gayet,

I Streuli, FX Aubriot

Intestinal surgery

B Dousset, M Leconte, S Gaujoux

Radiology

AE Millischer

Laboratory: Genetic

D Vaiman, F Mondon, S Barbaux

Laboratory: Imunulogy B Weill, F Batteux, S Chauzenoux

C Nicco, C Chéreau

Laboratory: Reproductive biology JP Wolf, V Lange, K Pocate,

JM Kuntzman, C Chalas

Statistical unit

F Goffinet, PY Ancel

D. de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit,

A. Gompel, Professor and Head, Medical Gynecological unit,

C. Chapron, Professor and Chair, Dpt Gynecology Obstetrics II and Reproductive Medicine

Presence of endometrial

tissue outside of the uterus

DIE

OMA

SUP

A healthcare concern:

1. Prevalence

2. Pain and infertility

3. Cost

Endometriosis: Definitions

Pathogenesis

is poorly

understood

Endometriosis: Clinical appearance

* Superficial OSIS

* Adhesions

* Ovarian endometriomas

* Deep endometriosis

Heterogeneous

disease ++++

Endometriosis: implantation theory

Adenomyosis SUP OMA DIE

SUP, superficial lesion; OMA, endometrioma; DIE, deep infiltrating endometriosis

Deep endometriosis: Definitions

Hum Reprod (2010)

JC Noel (2010)

JC Noel (2010)

Invasion of

the muscularis propria

Endometriosis: Diagnosis process

Onset of

the symptoms

Surgical diagnosis

and treatment

6 to 10 years

17

11 13

7

47

6

0

10

20

30

40

50

1 2 3 4 ≥5 ?

Perc

ent

%

Nb of times doctor seen

Ballweg ML 2004

Endometriosis: Diagnosis process

Nnoaham et al.,

Fertil Steril (2011)

16 centers

10 countries

N = 745 osis

3.3 ± 3.6 years

10.7 ± 9.3 years

Endometriosis: Clinical symptoms

Infertility Pelvic pain

Bleeding

Relationship between endometriosis

and chronic pelvic pain

Pelvic pain

Endometriosis

Symptomatic No pain

symptoms

Adaptated from Hurd Obstet Gynecol (1998)

Endometriosis: Diagnosis process

Sinaii et al., Fertil Steril (2008)

Multi

association

Ballweg ML (2004)

Multi

symptoms

disease

Endometriosis: Diagnosis process

Painful symptoms

related to

menstruation

Endometriosis: Diagnosis process

Ballweg ML (2004)

Onset of symptoms

Adolescents 67.1%

Adults 39.2%

Age of

1st pelvic symptoms

Greene et al., Fertil Steril (2009)

Onset of symptoms Time from seeking

medical attention

to diagnosis

Adolescents 6.0 ± 0.2 years

Adults 2.0 ± 0.3 years

DIE: Importance of questioning

Parameters

No DIE (n = 131)

DIE (n = 98)

p

OR 95% CI

1st degree- relatives

family history of

endometriosis

6

(4.6%)

13

(13.3%)

0.02

3.2

(1.2 - 8.8)

Chapron et al., Fertil Steril (2011)

DIE: Importance of questioning

Parameters

No DIE (n = 131)

DIE (n = 98)

p

OR 95% CI

Absenteism

from school

during

Menstruation

33 (25.2%)

37 (37.7%)

0.04

1.7 (1 - 3)

Chapron et al., Fertil Steril (2011)

DIE: Importance of questioning

Parameters

No DIE (n = 131)

DIE (n = 98)

p

OR 95% CI

Prescription of OCPs

because of severe 1st DM

15 (25.9%) 29 (58.0%) 0.001 4.5 (1.9 - 10.4)

Age (years) 18.1 ± 3.2 16.5 ± 2.4 0.07

Duration of use (years) 5.1 ± 3.8 8.4 ± 4.2 0.02

Chapron et al., Fertil Steril (2011)

DIE: Importance of questioning

Chapron et al., Fertil Steril (2011)

Endometriosis

and oral contraceptives

Chapron et al., Hum Reprod (2011)

OC user SUP * OMAs * DIE *

Never user Reference Reference Reference

Ever user 2.59 (1.11 - 6.03) 1.37 (0.84 - 2.23) 4.2 (1.54 - 11.2)

Current user 2.7 (0.98 - 7.47) 0.95 (0.5 - 1.7) 1.98 (0.65 - 6.07)

Past user 2.56 (1.07 - 6.09) 1.65 (0.99 - 2.75) 5.7 (2.1 - 15.7)

*: Ad OR 95% CI

Deep endometriosis: Rectal wall infiltration

N Se Sp PPV NPV

TRUS

Chapron et al., (2004) 81 97 89 87 98

Bazot et al., (2007) 81 89 93 96 81

Piketty - Chapron (2009) 134 96 100 100 95

MRI

Chapron et al., (2004) 81 76 98 96 85

Abrao et al., (2007) 104 83 98 97 84

Bazot et al. (2007) 88 83 93 96 79

TVUS

Abrao et al. (2007) 104 98 100 100 98

Bazot et al., (2007) 81 93 100 100 87

Piketty – Chapron (2009) 134 90 96 97 89

0

50

100

1er

trim.

3e

trim.

Est

Ouest

NordTRUS

MRI

TVUS

Deep endometriosis: Preoperative diagnosis

Hum Reprod

(2009)

Deeply infiltrating endometriosis: Location: n = 959 patients

Main N Associated lesions Total

lesion USL Va Bl In Ur

R L B

Bladder 75 2 9 6 5 75 97

USL 354 93 175 172 440

Vagina 107 16 22 40 107 185

Intestine 360 59 48 206 201 36 690 1247

Ureter 63 6 13 44 38 13 104 70 288

Total 959 176 267 468 351 124 794 70 2257

Chapron et al., (October 2013) Multifocality +++

Intestinal

endometriosis Anatomic distribution

(n = 413 patients)

Main characteristics N %

Unique without other DIE lesions 41 9.9

Multifocal intestinal DIE lesions 205 49.6

Associated right/left lesions 81 19.6

Bifocal intestinal DIE

MRI: intestinal DIE

Chapron - Dousset (April 2013)

Bowel Deep Endometriosis: Location of microscopic infiltration

(n = 50 patients)

Kavallaris et al., Hum Reprod (2003)

Endometriotic lesions N %

Multifocal (< 2 cm) 31 62

Multicentric ( 2 cm) 19 38

Unicentric and unilocular

0

0

Intestinal

endometriosis Anatomic distribution

(n = 413 patients)

Main characteristics N %

Unique without other DIE lesions 41 9.9

Multifocal intestinal DIE lesions 205 49.6

Associated right/left lesions 81 19.6

Bifocal intestinal DIE

MRI: intestinal DIE

Chapron - Dousset (April 2013)

Severe ureteral

endometriosis Associated DIE lesions

(n = 63 patients)

DIE lesions N % N

USL 41 65.1 63

Vagin 38 63.6 38

Bladder 13 20.6 13

Intestine 53 84.1 104

Ureter 63 100.0 70

Total 63 288

Chapron - Dousset (2013)

Main Patients DIE lesions

4.5 ± 2.5 (range 1 – 17)

Ureteral DIE

is associated

with intestinal DIE

in 84%

Deep endometriosis: Preoperative work-up importance of imaging

TransRectal US MRI

TransVaginal US Kidney scintigraphy

Uro - MRI

Surgery for endometriosis (n = 790 patients)

No (n = 471; 60%) Yes (n = 309; 40%)

SUP 109 (23.1%) 22 (7.1%)

OMA 152 (32.3%) 45 (14.6%)

DIE 210 (44.6%) 242 (78.3%) 4.5

(3.2 - 6.2)

- DIE isolated 144 (68.6%) 138 (57.0%)

- DIE + OMA 66 (31.4%) 104 (43.0%)

Endometriotic

lesions

Previous surgery for Osis OR

95% CI

Sibiude - Chapron et al., Obstet Gynecol (2014)

Surgery for endometriosis (n = 790 patients)

Worst DIE lesion Previous surgery for Osis OR 95% CI

No (n = 471;

60%)

Yes (n = 309; 40%)

USL 71 (34.0%) 32 (13.3)

Vagina 21 (10.0%) 16 (6.7%)

Bladder 18 (8.6%) 17 (7.0%)

Intestine 77 (36.8%) 159 (66.0%) 3.2

(2.1 - 4.8)

Ureter 22 (10.5%) 17 (7.0%)

Sibiude - Chapron et al., Obstet Gynecol (2014)

Surgery for endometriosis (n = 790 patients)

DIE lesion Previous surgery

for endometriosis

OR 95% CI

No (n = 471;

60%)

Yes (n = 309; 40%)

Number

1 - 2 130 (62.2%) 107 (44.2%)

≥ 3 79 (37.8%) 135 (55.8%) 2.1 (1.4 - 3.0)

Mean

number

2.6 ± 1.8 3.1 ± 1.9

< 0.001

Sibiude - Chapron et al., Obstet Gynecol (2014)

Surgery for endometriosis (n = 790 patients)

Endometriotic

lesion

Previous surgery

for endometriosis

OR 95% CI

classification 1 or 2

(n = 263)

≥ 3

(n = 46)

SUP 20 (7.6%) 2 (4.3%)

OMA 45 (17.1%) 0 (0.0%)

DIE 198 (75.3%) 44 (95.7%)

14.4 (2.0 -

106.9)

Sibiude - Chapron et al., Obstet Gynecol (2014)

Coef = 0.62, 95% CI 0.47-0.77, p<0.0001

Nu

mb

er

of

DIE

le

sio

ns

Determinants for existence of DIE: Results with multiple logistic regression analysis

AOR (95% CI) p

Previous surgery (yes vs no) 2.7 (1.7-4.3) <0.001

Previous surgery for endometriosis (n = 790 patients)

Sibiude - Chapron et al., Obstet Gynecol (2014)

Endometriosis: Surgical management

Disease Surgery

Progression

Recurrence

Unnecessary

Inappropriate

?

Obstet Gynecol (2014)

Take home

messages

Strategy

- Multidisciplinary management

Endometriosis

and

Patients

- Global approach

Surgery

Medical Ttt

AR

T

SUP OMAs DIE

Adenomyosis

Pelvic pain

Infertility

Take home

messages

Pelvic pain

Endometriosis Symptoms related to menstruation

Deep endometriosis Pelvic pain intensity

Family history

Adolescent period: absenteism

OC pills prescription for pain

Intestinal DIE Menstrual rectorrhagia

Imaging: 1st TVUS

Mutifocality