ENDOMETRIOSIS Akmal Abbasi. DEFINITION The presence of functional endometrial tissue outside the...

ENDOMETRIOSIS

Akmal Abbasi

DEFINITION

•The presence of functional endometrial tissue outside the uterine cavity.

EPIDEMIOLOGYAffects 5-20% of all women of

childbearing age.

Mean age of diagnosis 25-29yrs

No racial difference in prevalence.

Sites

• Pelvic• Extra pelvic• Umbilicus.• Scars (Lap.).• Lungs & plura.• Others.

Pelvic Endometriosis

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

ETIOLOGY

•Three main theories of pathogenesis

•Retrograde transport of endometrial tissue through the fallopian tubes at menstruation leading to seed of the peritoneal cavity.

ETIOLOGY

•Metaplastic transformation of coelomic epithelium leading to functioning endometrial tissue extra pelvic sites.

ETIOLOGY

• Spread of endometrial tissue through lymphatic and vascular channels.

• Possibility of autoimmune cause.

• Possible role of toxic chemical exposure.

SYMPTOMSDysmenorrhea.

Dyspareunia.

Infertility.

Menstrual irregularities.

Chronic pelvic pain.

Age at Diagnosis< 196%

19 – 2524%

26 –3552%

36 –4515%

> 453%

CLINICAL FINDINGSNormal Physical exam even with

moderate to severe endometriosis.

Fixed retroversion of uterus.

Rectovaginal exam

•Uteroscral or rectovaginal septum nodularity

CLINICAL FINDINGS

Pelvic exam (premenstrual )

•Fixed uterine retroversion.

•CMT.

•Adenexal tenderness.

•Adenexal masses- endometrioma (Chocolate cyst) of the ovary- (15cm)

DIFFERENTIAL DIAGNOSIS

Chronic PID.Pelvic adhesions from PIDPrior surgery.Ovarian cysts.Ovarian tumors.

LAB EVALUATION

CA 125•Found repeatedly in patients.

•Not recommended for screening.GC and chlamydia.CBCUrinalysis.

DIAGNOSTIC EVALUTIOAN

Ultrasound

• Identification of cysts.

•Cannot detect focal implants.

MRI

•Sensitivity and specificity very low.

DIAGNOSTIC EVALUTIOAN

Visualization by Laparoscopy or laparotomy considered the gold standard of for diagnosis.

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

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

TREATMENT

Optimal treatment regimen depends on

Desired pain relief.

Desired fertility.

TREATMENTSurgeryConservativePreserve reproductive organs

Use of laser or thermal cautery.

Adhesiolysis via laporoscopy or laparatomy.

1/3 of patients have a recurrence.

TREATMENTSurgeryRadical (definitive procedure)

•Hysterectomy with salpingo-oophorectomy.

•90% of patients pain free.

•Not for women desiring pregnancy.

TREATMENT

Drugs of choiceDanazol (Danocrine).GnRH agonistsProgesterons

TREATMENTDanazol (Danocrine).Derivative of 17-ethinyl testosterone.

400mg – 800mg b.i.d to q.I.d.

Creates high androgen ,low estrogen state with anovulation and amenorrhea , inhibits the the growth of endometrial tissue.

6mths or 2wks if as adjunct therapy.

TREATMENTGnRH agonists (creates hypoestrogenic state) Usually 6mth duration of treatment)

Nafarelin acetate (Synarel)• 0.2 – 0.4mg intranasally b.i.d.

Leuprolide acetate ( Luprom)• 3.75mg IM monthly (depot).

• 0.5 – 1.0mg SQ daily.

TREATMENTProgesterons (causes atrophy of endometium)

Depo-Provera• 100mg q2wks PO for 4 doses.

• Then 200mg monthly for 4 mths.

Medroxyprogesterone acetate (MPA)• 30mg PO Daily for 3 mths.

• Depot may cause prolonged anovulation.

TREATMENT

ALTERNATIVE DRUGSCombined estrogen –progesterone

•OCs with 30 to 35g ethinyl estradiol to produce amenorrhea.

•Less effective than other meds.

•Use if other drugs are contraindicated.

TREATMENTNSAIDs may be effective for pain relief

Patient educationAvoid delaying

childbirth once diagnnosis is made.