1. Treatment of pelvic pain due to endometriosis
Dr zahra asgari
Associated professor of ob/gyn
Endosurgeury
Arash hospital

2. TREATMENT
Expectant management
Medical management
Surgical management

3. Expectant management is considered for two groups of patients:
women with no or minimal symptoms
perimenopausal women.

4. MEDICAL TREATMENT  
pelvic pain and suspected endometriosis  empiric medical therapy prior to establishing a definitive diagnosis by laparoscopy
analgesics and/or combined oral estrogen-progestin contraceptives for women with no more than mild pelvic pain
GnRH agonist for those with moderate to severe pelvic pain.

5. 80 to 90 percent of patients some improvement in symptoms with medical therapy
medical interventions neither enhance fertility nor diminish endometriomas or adhesions
women with suspected endometriomas and advanced stages of disease, or infertility, are more appropriately managed surgically

6. Surgical management of pelvic pain due to endometriosis

7. INDICATIONS(diagnosis and management )
●Failure of medical therapy or contraindications to medical therapy
●Need for a definitive diagnosis of endometriosis (definitive diagnosis requires surgery to visualize and/or biopsy lesions)
●Exclude malignancy in an adnexal mass
●Treatment of infertility in selected women
●Obstruction of the urinary tract or bowel

8. SURGICAL PLANNING should be counseled about their options
They should be counseled about the choice between conservative or definitive surgery( conservative treatment procedures are performed laparoscopically, but extensive disease may require laparotomy)

9. Conservative versus definitive surgery
Conservative surgery is typically used as the initial surgical treatment for endometriosis(excision or ablation of endometriotic lesions with the intent of preserving the uterus and as much ovarian tissue as possible), nerve transection procedures
Women with recurrent symptoms may be treated with either repeat conservative surgery or definitive surgery.(hysterectomy combined with bilateral salpingo-oophorectomy)
women wish to preserve reproductive and endocrine function, and thus, hysterectomy alone or hysterectomy plus unilateral salpingo-oophorectomy is often performed for pain caused by endometriosis

10. The choice between conservative and definitive surgery
efficacy and potential morbidity of the procedure
the patient’s plans for future childbearing
and patient preference.
Definitive surgery is typically performed after medical therapy and one or more conservative procedures have failed(decide whether to remove or conserve the ovaries)

11. Conservative surgery
advantages :effective( at least in the short term)
associated with less morbidity than definitive surgery
disadvantage :rate of recurrent symptoms is higher than for definitive surgery

12. definitive surgery : perioperative complications and recovery
hormonal function and body image
hysterectomy is associated with a higher complication rate than laparoscopic treatment of endometriosis
Some women who undergo hysterectomy may experience regret or a change in body image

13. In terms of efficacy, in the short term, conservative surgery and hysterectomy appear comparable
rate of reoperation for recurrent pain at one year after either laparoscopic treatment or hysterectomy was similar (0 to 5 percent)

14. it appears that hysterectomy alone is an effective treatment for pain symptoms of endometriosis.
Oophorectomy likely increases the efficacy of definitive surgery, but is also accompanied by the quality of life issues and potential adverse health effects of premature menopause
There are no data to establish a specific age threshold for which the benefit of oophorectomy for treatment of endometriosis pain outweighs the risks of premature menopause

15. counsel all women undergoing definitive surgery about the risks and benefits of oophorectomy
we tend to discourage oophorectomy in women younger than 40 years
Women approaching the average age of menopause (51 years) are more likely to choose oophorectomy since they may reduce the risk of recurrent pain symptoms while losing fewer years of hormonal function

16. Suspicion of deep infiltrating lesions or extrapelvic disease
DIE: refers to lesions that penetrate to a depth of 5 mm or more
multifocal and may involve the uterosacral ligaments, rectovaginal space, bowel, ureteral and/or bladder
deep infiltrating endometriosis occurred without disease at other sites in only 6.5 percent of patients
DIE is suspected based on symptomatology (eg, dysuria, dyschezia, hematochezia) and/or physical examination (eg, uterosacral ligament tenderness with dense nodules, non-mobile uterus)

17. recommendations regarding conservative and definitive
●Conservative surgery is the first-line option for most women planning surgical treatment of endometriosis

18. continue
suggest hysterectomy rather than conservative surgery ONLY for women with persistent bothersome symptoms of endometriosis who do not plan future childbearing and who have both failed medical therapy and at least one conservative treatment procedure
Definitive surgery is also reasonable for women who have additional indications for hysterectomy

19. For women undergoing hysterectomy for treatment of endometriosis►bilateral salpingo-oophorectomy ONLY for those who value decreasing the risk of reoperation more than avoiding the risks of premature menopause
preference for oophorectomy ► woman approaches menopause
Oophorectomy is also reasonable for women with extensive disease involving the ovaries.  

20. the preoperative evaluation should include appropriate additional testing
This includes evaluation of the urinary or gastrointestinal tract
magnetic resonance imaging (MRI) or rectal sonography may suggest an obliterated pelvic cul-de-sac
transvaginal ultrasonography, one can look for the “sliding sign” when placing the probe in the posterior fornix to see if the anterior rectal wall glides smoothly over the retro-cervix. If there is no such sliding observed, then there is a high probability of obliteration of the cul-de-sac by endometriosis

21. Preoperative medical suppressive therapy
Hormonal suppression has been used prior to surgery to decrease the size of endometriotic implants, thereby reducing the extent of surgery required
there is no evidence that preoperative hormonal intervention decreases the extent of surgical dissection required to remove implants, prolongs the duration of pain relief, increases future pregnancy rates, or decreases recurrence rates
Use of preoperative GnRH agonists reduced disease seen at the time of the second surgery, but there was no evidence that this translated into prolonged duration of pain relief or a decreased recurrence rate

22. Antibiotic prophylaxis
Operative laparoscopy is typically a clean procedure, and antibiotic prophylaxis is not generally used
we give prophylactic antibiotics to patients if there is suspicion of adhesive bowel disease, based upon the increased risk of bowel injury

23. Thromboprophylaxis
Use of mechanical or pharmacologic prophylaxis depends upon the procedure and patient risk factors
Bowel preparation is not routine in current practice prior to surgery for endometriosis.

24. Ablation versus excision 
The choice of modality is based upon surgeon experience and preference
Two randomized trials comparing excision with ablation (monopolar electrosurgery in one trial, diathermic ablation in the other) found no difference in pain scores at 6 to 12 months
any difference is likely of trivial clinical significance. There are no high quality data comparing among the various ablative modalities (laser, electrosurgery, ultrasound)

25. Adhesiolysis
adhesive disease; the reported rate is 70 percent in women with and without prior surgery
Red lesions are associated with more adhesions than women with only black, white and/or clear lesions
, surgery to ameliorate the adhesions is not always effective
we perform adhesiolysis selectively
We resect all adhesions that may compromise fertility or that correspond to the location of the patient’s pain.
Surgical management of DIE requires specialized skills to adequately remove extensive disease
The goal is to re-establish normal anatomy

26. POSTOPERATIVE CARE Postoperative medical therapy :
We recommend postoperative medical suppressive therapy for most women treated surgically for endometriosis
hormonal therapy increased the duration of pain relief and delayed recurrence of disease
postoperative insertion of the levonorgestrel-releasing intrauterine device (LNG IUD) results in decreased dysmenorrhea compared with expectant management
first-line therapy is estrogen-progestin contraceptives or oral progestins alone, both of which are easy to tolerate and cost-effective.
Another option is a LNG IUD
GnRH
Hormonal treatment is typically not necessary following oophorectomy.
Suppression with a progestin is appropriate if symptoms recur after hysterectomy and oophorectomy
Use of a progestin may be contraindicated in women with risk factors for breast cancer.

27. Postmenopausal hormone therapy after oophorectomy
Postmenopausal hormone therapy with low-dose estrogen (equivalent of mg conjugated equine estrogens) is not contraindicated in women following an oophorectomy for endometriosis.
Treatment may be initiated immediately after surgery
the probability of a recurrence in women treated with estrogen therapy is very low (3.5 percent)
There is no evidence to support the addition of a progestin to prevent malignant transformation in residual endometriosis lesions or to help suppress growth of such tissue

28. Repeat surgery 
Pelvic pain symptoms often recur after conservative surgical treatment of endometriosis
A patient who presents with recurrent pelvic pain following surgical treatment should be evaluated to ensure that the most likely cause is endometriosis
If the patient is not on medical therapy, medical therapy should be initiated and other modalities may be helpful (eg, pelvic physical therapy)
Surgery may be the only option if a woman has had severe adverse effects from hormonal therapy.
For women who have undergone conservative surgery, the patient should be counseled regarding whether to undergo further conservative surgery or definitive surgery