Definition: Ectopic Endometrial Tissue

True Incidence Unknown: ? 1-5%Does NOT Discriminate by RaceHistology: Endometrial Glands with

Stroma +/- Inflammatory Reaction

Chronic Pelvic Pain, Dysmenorrhea (90%)

Abnormal Uterine Bleeding Infertility (55% )Deep DyspareuniaPelvic Mass (Endometrioma)Misc: Tenesmus, Hematuria, LBP,

Hemoptysis

< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%

Sampson: “Retrograde Menstruation”

Hematologic SpreadLymphatic SpreadCoelomic MetaplasiaGenetic Factors Immune FactorsCombination of the AboveNo Single Theory Explains All Cases of

Endometriosis

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

History, Imaging StudiesBiopsy Preferable Over Visual

Inspection

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

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

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

IS TREATMENT ALWAYS REQUIRED?WHO NEEDS TREATMENT?DOES ANY TREATMENT REALLY

WORK?DOES TREATMENT IN YOUNG

WOMEN PREVENT INFERTILITY AND PROGRESSION?

ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE

SPONtan REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES

NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD

COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP

PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSIS—PERSISTENCE, REGRESSION AND PROGRESSION

ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT

LAPAROSCOPIC ABLATION OF VISIBLE ENDOmetriosis IN INFERTILE WOMEN IS ASSOCiate WITH SIGNIFICANTLY INCREASED FERTILITY RATES

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 Chronic Pelvic Pain SYNDROME

Single/nulliparousEarly menarcheNon oral contraceptionNon smoker shorter cycle/longer

duration of flowDysplastic naevus syndrome,

melanoma

Adhesions distorsion

Increased PGs

Cell mediated gamete inj

Defective folliculogenisis

Chronic salpingitis

Activated macrophag

Increased prev. ABs

LUFS

Altered tubal motil

Cytokines Fertilization failure

hyperprolactinaemia

Impaired oocyte pick up

Sperm phagocytosed

Early spon abortion

Luteal phase deficency

NSAIDsOCPs (Continuous)ProgestinsDanazolGnRH-aGnRH-a + Add-Back TherapyMisc: Opoids, TCAs, SSRIs

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

Medical TreatmentsChoose OCPs with Least Estrogenic

Effects, Maximal Androgenic / Progestin Effects

May be as Effective as GnRH-a for Pain Control

MPA 10-30 mg/day, DP 150 mg Semi-Monthly

May be Taken Long-TermRelatively InexpensiveSide-Effects: AUB, Mood Swings,

Weight Gain, Amenorrhea

PSYCO-PHYSICAL TREATMENTS-ACCUPUNCTURE, MASSAGE, RELAXATION, TENS

EXERCISEANTI-OESTROGEN DRUGSLAPAROSCOPY/ OPEN SURGERY

Weak AndrogenSuppresses LH / FSHCauses Endometrial Regression,

AtrophyExpensiveSide-Effects: Weight Gain,

Masculinization, Occ. Permanent Vocal Changes

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 )

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

PREG RATE

n

NO TREAT

44% 235

DRUG THERAPY

41% 418

SURGERY

65% 912

IVF 20 257

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