1. Endometriosis
Dr.Mona Shroff M.D

2. Endometriosis Definition: Ectopic Endometrial Tissue
True Incidence Unknown: ? 1-5%
Does NOT Discriminate by Race
Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

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

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

6. Prevalence

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 Bleeding
Infertility
Deep Dyspareunia
Pelvic 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 Spread
Lymphatic Spread
Coelomic Metaplasia
Genetic Factors
Immune Factors
Combination of the Above
No Single Theory Explains All Cases of Endometriosis

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

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

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

17. Treatment : Consideration
Age.
Symptoms.
Stage.
Infertility.

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

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

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). 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 .

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 Menstruation
Lower Fertility Rates than Other Medical Treatments
Choose 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-Monthly
May be Taken Long-Term
Relatively Inexpensive
Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea

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

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 )

28. 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 .

29. 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

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 Bleeding
The Optimal Treatment Remains Unclear
Surgical Excision is the Most Efficacious Approach with Respect to Fertility
Better Medical Therapies are Needed