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

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Presentation on theme: "Dr.Mona Shroff M.D. Department of Obstetrics and Gynecology SMIMER"— Presentation transcript:

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

5 Dr Mona Shroff

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

13 Dr Mona Shroff

14 Dr Mona Shroff

15 Dr Mona Shroff

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

19 Dr Mona Shroff

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

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