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Prof. Rafia BalochHead of Department
Gynaecology & Obstetrics SZWH, CMC & SMBBMU Larkana
Learning Objectives
• Identify the symptoms and consequences associated with endometriosis
• Describe various treatment options in the management of endometriosis
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
Definition• Endometriosis is a disease in which
endometrial glands and stroma implant and grow in areas outside the uterus
• Most commonly implants are found in the pelvis
• Lesions may occur at distant sites: pleural cavity, liver, kidney, gluteal muscles, bladder, etc
Features of Endometriosis
• Prevalence 2-50% of women; 21-47% of infertility cases
• Exposure to ovarian hormones appears to be essential
• No known racial or socioeconomic predilection
• Severe disease may occur in families
Is Endometriosis Increasing?• 1965-1984, endometriosis rose from 10 to 19% as
primary indication for hysterectomy
• Simultaneously, a trend of more conservative therapies was occurring, which suggests a true increase in the incidence
• Theories include delay of childbearing, less use of OCs, and exposure to environmental toxins such as dioxin
Etiologies of Endometriosis• Sampson's theory: Retrograde menses and peritoneal
implantation– Most women retrograde menstruate
• Meyer's theory: Coelomic metaplasia– Low incidence of pleural disease
• Halban's theory: Hematogenous or lymphatic spread to distant tissues – Does not explain gravity dependent disease sites
• Immunogenic defect
Normal Pelvic Structures
Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis
4* 9
11429
* Revised AFS Score
Clinical Presentation
• Pelvic pain
• Infertility
• Pelvic mass
Pelvic Pain• Frequency
– Cyclic: Variable length prior to and after menses
– Acyclic: constant and unrelenting
• Associated activities– May include dyspareunia, dysuria, or
dyschezia• Other sites of pain
– Muscle regions– Distant tissues
Infertility• Moderate to severe disease
– Adhesions – Distortion of normal anatomy– Prevent sperm-egg interaction
• Minimal to mild disease– Mild infertility– Mechanism(s) unknown
symptoms
• 90% severe dysmenorrohoea• 70% chronic pelvic pain• 75% dyspareunia• 55% infertility
Risk factors
• Single/nulliparous• Early menarche• Non oral contraception• Non smoker shorter cycle/longer duration of flow• Dysplastic naevus syndrome, melanoma
Physical Findings
• Tender nodules along the uterosacral ligaments or in the cul-de-sac, especially just before menses
• Pain or induration without nodules commonly in the cul-de-sac or rectovaginal septum
• Uterine or adnexal fixation, or an adnexal mass
Diagnosis of Endometriosis• Direct visualization of implants
– Laparoscopically– Conscious pain mapping
• Imaging of endometriomas– MR appears to be best (3 mm implants)– Ultrasound helpful in office setting
• Biochemical markers – Lack specificity
Endometriosis
Ultrasound of Endometrioma
MR of Endometrioma
Endometrioma
Familial association
• Relative Risk to siblings 2.3 overall
• Relative Risk to sibs if severe endo 15
Infertility mechanisms
Adhesions distorsion
Increased PGs
Cell mediated gamete inj
Defective folliculogenisis
Chronic salpingitis
Activated macrophag
Increased prev. ABs
LUFFS
Altered tubal motil
Cytokines Fertilization failure
hyperprolactinaemia
Impaired oocyte pick up
Sperm phagocytosed
Early spon abortion
Luteal phase deficency
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
treatment of menstrual painTreatment level of evidenceSimple analgesics 1Herbal remedies 1 alcohol 2Antidepressants/anxiolytics 2OCPs 1NSAIDS 3
ENDOMETRIOSIS PAIN
• PSYCO-PHYSICAL TREATMENTS-ACCUPUNCTURE, MESSAGE, RELAXATION, TENS
• EXERCISE• ANTI-OESTROGEN DRUGS• LAPAROSCOPY/ OPEN SURGERY
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
Treatment of Endometriosis
• Management of pain– Surgery – Medical therapy
• Treatment of infertility– Surgery– Ovulation induction– Assisted reproductive technology
Endometriosis
Removal of Endometriosis
Dissection of an Endometrioma
Tube
OvaryIncision
Removal Result
Treatment of Pain• Medical management
(ovarian suppression, removal of estrogen)
– Oral contraceptives, progestin, danazol
– GnRH agonist with add-back
– Alternating GnRH agonist and OCs
– Aromatase inhibitors
Medical Treatment
Ovary EstrogenEndometriosis
Tissue
Medical Treatment
Ovary EstrogenEndometriosis
TissueOral contraceptivesDanazolGnRH agonists
Progestin
Role of Estrogen in Endometriosis
Estrogen
Role of Estrogen in Endometriosis
Estrogen
Cell growth
Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
Aromatase In Endometriosis• Aromatase is key for the biosynthesis of estrogen
• In patients aromatase expression is higher in endometriosis tissue than in normal endometrium
• In endometriosis tissue aromatase activity is stimulated by prostaglandin
• Estrogen synthesized by endometriotic tissue stimulates growth of lesions
Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
Aromatase Inhibitors • Letrozole
• Exemestane • Anastrozole
Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
Aromatase Inhibitors • Letrozole
• Exemestane • Anastrozole• Danazol
Treatment of Infertility• Removal of disease
– Surgery improve conception rates at all stages
• Ovulation induction– Gonadotropins with ovarian suppression – Insemination with either clomiphene or FSH
• Medical suppression of ovarian function– No benefit
• Assisted reproductive technology
Prevention
• Early marriage• Avoid Vaginal examination during menses• Surgery during menses• Early Treatment of cryptomenorrhea
MESSAGE
• Live only for a love of Allah follow Holy Quran & Prophet Hazrat Muhammad ملسو هيلع هللا ىلص
