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

2. 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.
Dr Mona Shroff

3. - Pelvic - Extra pelvic Sites Umbilicus. Scars (Lap.). Lungs & plura.
Others.
Dr Mona Shroff

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

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6. Prevalence

7. Age at Diagnosis > 45 < 19 36 –45 3% 6% 15% 19 – 25 24% 26 –35
52%
Dr Mona Shroff

8. Signs and Symptoms Chronic Pelvic Pain, Dysmenorrhea
Abnormal Uterine Bleeding
Infertility
Deep Dyspareunia
Pelvic Mass (Endometrioma)
Misc: Tenesmus, Hematuria, Hemoptysis
Dr Mona Shroff

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.
Dr Mona Shroff

10. Etiology: Theories Sampson: “Retrograde Menstruation”
Hematologic Spread
Lymphatic Spread
Coelomic Metaplasia
Genetic Factors
Immune Factors
Combination of the Above
No Single Theory Explains All Cases of Endometriosis
Dr Mona Shroff

11. Diagnosis Laparoscopy (“Gold Standard) Laparotomy
Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies
Biopsy Preferable Over Visual Inspection
Dr Mona Shroff

12. Appearance Endometriosis May Appear Brown Black (“Powderburn”)
Clear (“Atypical”)
Endometriosis May Be Associated with Peritoneal Windows
Dr Mona Shroff

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16. 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
Dr Mona Shroff

17. Treatment : Consideration
Age.
Symptoms.
Stage.
Infertility.
Dr Mona Shroff

18. 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
Dr Mona Shroff

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

21. 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.
Dr Mona Shroff

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). or
2. 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 .
Dr Mona Shroff

23. Aim of the hormonal therapy cont….
(B) Pseudomenopause (induction of amenorrhoea) by:
1. Danazol.
2. Gn RH analogues.
3. Gestrinone.
4. Gossypol.
Dr Mona Shroff

24. Continuous OCPs “Pseudopregnancy” (Kistner)
? Minimizes Retrograde Menstruation
Lower Fertility Rates than Other Medical Treatments
Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects
Dr Mona Shroff

25. Progestins May be as Effective as GnRH-a for Pain Control
MPA mg/day, DP 150 mg Semi-Monthly
May be Taken Long-Term
Relatively Inexpensive
Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea
Dr Mona Shroff

26. Danazol Weak Androgen Suppresses LH / FSH
Causes Endometrial Regression, Atrophy
Expensive
Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes
Dr Mona Shroff

27. 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 )
Dr Mona Shroff

28. 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
Dr Mona Shroff

29. 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 ovari­an steroidogenesis .
The dose is mg orally twice weekly .
Dr Mona Shroff

30. 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
Dr Mona Shroff

31. 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
Dr Mona Shroff

32. 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