1. CLINICAL GUIDELINE FOR THE TREATMENT OF ENDOMETRIOSIS

2. Endometriosis Endometriosis is a disorder in which cells lining the uterus (endometrium) implant in other locations in the body. Typically these cells can implant on the ovaries, bowel, rectum, bladder and the pelvic lining. Occasionally, some implants can travel to distant organs such as the lung, brain, and kidney.

3. Endometriosis These estrogen dependent implants grow and cause strictures and adhesions on organs. These ectopic implants distort and obstruct the organ’s normal function thereby causing pain, bleeding and infertility.

4. Endometriosis The pathogenesis is unknown. Theories include: Retrograde menstruation Genetic allele HLA-B7

5. Endometriosis Found in 5-10% of women of reproductive age in the US. Found in 53% of adolescents who present with pelvic pain. Higher incidence in Caucasian women and in women with lower BMIs.

6. Endometriosis A woman with a first degree relative diagnosed with endometriosis is 6 times more likely to develop this condition. Early menarche, nulliparity, frequent cycles, menses lasting 7 days or more, and a closed hymen.

7. Female Reproductive System www.Patient.co.uk/diagrams.asp

8. Sites of Ectopic Implants in Red

9. Signs and Symptoms Some women are asymptomatic even with severe cases. Pelvic pain is the most common. Dyspareunia. Bleeding with defecation, urination, or intercourse. Inability to conceive.

10. Staging of Endometriosis Staging does not classify the condition according to the severity of pain or other symptoms. Staging is meant to predict the chance of pregnancy. Points are arbitrarily assigned by the physician interpreting the laparoscopy results.

11. Laparoscopy Procedure

12. Endometrial Changes

13. Stage I/ Minimal 1-5 Points Endometriosis implants appear as red dots in these photos. There are isolated and superficial implants growing outside the uterus. Endochick.wordpress.com

14. Stage ll/ Mild 6-15 Points Deep lesions present in the cul-de-sac area between the uterus and the rectum. Endochick.wordpress.com

15. Stage III/ Moderate 16-40 Points Endochick.wordpress.com Implants are found on the ovaries. Symptoms are common at this stage.

16. Stage IV/ Severe >40 Points There are large sized implants and extensive adhesions on several organs. Infertility is common at this stage. Endochick.wordpress.com

17. Treatment Plan Treatment Options:Provides:Examples:Cost: NSAIDsMild pain relief.Motrin, Advil, Ibuprophen $4 List at Wal-Mart and Target AccupuncturePain relief in some women. Unknown Monophasic OCPsMild pain relief, slows progression. Apri, Cyclessa, Desogen, Ortho-cept $29.99/ 28 pack Free at Health Dept? Steroid with androgenSlows growth of implantsDanazol$68.60-$110.76 Low co pay ProgestinsPain relief in 80% of women, decreases growth of implants. Avgestin/Norethind-rone Acetate PO $89.57/ 30 tabs GnRH AgonistsInitial management & recurrent symptoms. Leuprolide IM Lupron Depo IM $355.76-$522.25/ Box Laparoscopy Laparotomy Relieves severe pain by removing implants by laser. May need to be repeated. $1,700-$5,000 HysterectomyRelieves severe pain, removal of ovaries provides cure. May need hormone therapy if the ovaries are removed. $5,000 Online.Epocrates.comDrugs.comMyMedicalCosts.comEMPR.com

18. References Bulun, S.. (2009). Endometriosis Mechanisms of Disease:. The New England Journal of Medicine, 360(3), 268-279. Retrieved January 11, 2010, from ProQuest Nursing & Allied Health Source. (Document ID: 1627865541). DeCherney, A., Nathan, L., Goodwin, T.M., & Laufer, N. (2007). Current diagnosis & treatment obstetrics & gynecology. New York: McGraw-Hill. Lee, S. (2009). Peritoneal Fluid Affects Release of IP-10 and IL-8 by Neutrophils and CD4+ T Cells. Fertility Weekly, 3-4. Retrieved from Health Source: Nursing/Academic Edition. www.nlm.nih.gov/medlineplus/ency/article/000915.htm www.Patient.co.uk/diagrams.asp