dr.mona shroff m.d. department of obstetrics and gynecology smimer dr mona shroff

Dr.Mona Shroff M.D.Department of Obstetrics and Gynecology SMIMER

Dr Mona Shroff www.obgyntoday.info

Endometriosis

Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% Histology: Endometrial Glands with

Stroma +/- Inflammatory Reaction Microscopic internal bleeding, with

the subsequent inflammatory response, neovascularization, and fibrosis formation, is responsible for the clinical consequences of this disease.


- Pelvic- Extra pelvic Umbilicus. Scars (Lap.). Lungs & plura. Others.


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


PrevalencePrevalence

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/1000woman-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

Age at Diagnosis

< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%


Signs and Symptoms

Chronic Pelvic Pain, Dysmenorrhea Abnormal Uterine Bleeding Infertility Deep Dyspareunia Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria,

Hemoptysis


Pelvic examination may reveal:

1. Pelvic tenderness. 2. Fixed retroverted uterus. 3. Nodularity of the Douglas pouch and

uterosacral ligaments. 4. Ovaries may be enlarged and tender .

Ovarian cyst may be detected.


Etiology: Theories

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

Endometriosis Dr Mona Shroff www.obgyntoday.info

Diagnosis

Laparoscopy (“Gold Standard) Laparotomy Inconclusive: CA-125, Pelvic Exam,

History, Imaging Studies Biopsy Preferable Over Visual

Inspection


Appearance

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

Endometriosis May Be Associated with Peritoneal Windows


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


Treatment : ConsiderationAge.

Symptoms.

Stage.

Infertility.Dr Mona Shroff www.obgyntoday.info

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


Pain Management: Medical Therapy NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Aromatase Inhibitors Misc: Opoids, SSRIs


Indications of Hormonal Rx

1. Small endometriotic; lesions.2. Recurrence after conservative

surgery.3. Preoperative for 6-12 weeks to

decrease size.4. Postoperative for residual lesions.5. When operation is contraindicated

or refused by the patient.


Aim of the hormonal therapy(A) Pseudopregnancy :1. Combined low - dose contraceptive pills(6 - 18

months to inhibit ovulation and menstruation and induce decidualization to endometriotic tissues).

or2. Progestins (to avoid oestrogen's side effects

medroxy progesterone acetate Depo medroxy progesterone acetate (DMPA) can be given in a dose of 150 mg IM every I - 3 months .


Aim of the hormonal therapy cont….

(B) Pseudomenopause (induction of amenorrhoea) by:

1. Danazol. 2. Gn RH analogues. 3. Gestrinone. 4. Gossypol.


Continuous OCPs

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

Medical Treatments Choose OCPs with Least Estrogenic

Effects, Maximal Androgenic / Progestin Effects


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


Danazol

Weak Androgen Suppresses LH / FSH Causes Endometrial Regression,

Atrophy Expensive Side-Effects: Weight Gain,

Masculinization, Occ. Permanent Vocal Changes


GnRH-a (Leuprolide,triptorelin)

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 )


Aromatase Inhibitors

Blocking the aromatase activity in extraovarian sites that suppress the conversion of androstenedione and testosterone to estrogen. May result in suppression of endometriosis at a local level.

Further studies needed 2.5 mg PO qd for 6 mo; administer

with norethindrone acetate 2.5 mg PO qd


Gestrinone It is a synthetic 19 Nor steroid exhibits

marked and - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties .

The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of ovari an steroidogenesis .

The dose is 2.5 - 5 mg orally twice weekly .


Surgical Treatment (Laparoscopy / Laparotomy)

Excision / Fulgration(ELECTROCAUTRY/LASER) Resection of Endometrioma Lysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve Ablation Presacral Neurectomy Appendectomy Uterine Suspension (? Efficacy) Hysterectomy +/- BSO


Issues

? Removal of Ovaries at Hysterectomy

? Need for Progestins if ERT Given ? Adjuvant Treatment Postoperatively ? Lupron Challenge Test for Diagnosis ? Is Endometriosis Best Treated

Surgically, Medically or Both


Conclusion

Endometriosis is a Common, Chronic Disease

Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding

The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious

Approach with Respect to Fertility Better Medical Therapies are Needed


dr.mona shroff m.d. department of obstetrics and gynecology smimer dr mona shroff

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