7 Age at Diagnosis > 45 < 19 36 –45 3% 6% 15% 19 – 25 24% 26 –35 52%
8 Signs and Symptoms Chronic Pelvic Pain, Dysmenorrhea Abnormal Uterine BleedingInfertilityDeep DyspareuniaPelvic Mass (Endometrioma)Misc: Tenesmus, Hematuria, Hemoptysis
9 Signs 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.
10 Etiology: Theories Sampson: “Retrograde Menstruation” Hematologic SpreadLymphatic SpreadCoelomic MetaplasiaGenetic FactorsImmune FactorsCombination of the AboveNo Single Theory Explains All Cases of Endometriosis
16 Treatment: Overall Approach Recognize Goals:– Pain Management– Preservation / Restoration of FertilityDiscuss with Patient:– Disease may be Chronic and Not Curable– Optimal Treatment Unproven or Nonexistent
18 Classification / Staging Several Proposed SchemesRevised AFS System: Most Often UsedRanges from Stage I (Minimal) to Stage IV (Severe)Staging Involves Location and Depth of Disease, Extent of Adhesions
21 Indications of Hormonal ttt 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.
22 Aim of the hormonal therapy (A) Pseudopregnancy :1. Combined low - dose contraceptive pills( 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 .
23 Aim of the hormonal therapy cont…. (B) Pseudomenopause (induction of amenorrhoea) by:1. Danazol.2. Gn RH analogues.3. Gestrinone.4. Gossypol.
24 Continuous OCPs “Pseudopregnancy” (Kistner) ? Minimizes Retrograde MenstruationLower Fertility Rates than Other Medical TreatmentsChoose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects
25 Progestins May be as Effective as GnRH-a for Pain Control MPA mg/day, DP 150 mg Semi-MonthlyMay be Taken Long-TermRelatively InexpensiveSide-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea
27 GnRH-a (Leuprolide,triptorelin) Initially Stimulate FSH / LH ReleaseDown-Regulates GnRH Receptors–”Pseudomenopause”Long-Term Success VariesExpensiveUse Limited by Hypoestrogenic EffectsMay be Combined with Add-Back (? >1 Year )
28 GestrinoneIt 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 ovarian steroidogenesis .The dose is mg orally twice weekly .
30 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
31 Conclusion Endometriosis is a Common, Chronic Disease Typical Symptoms Include Pain, Infertility, Abnormal Uterine BleedingThe Optimal Treatment Remains UnclearSurgical Excision is the Most Efficacious Approach with Respect to FertilityBetter Medical Therapies are Needed