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Endometriosis
Assoc.Prof.Pawin Puapornpong,
Faculty of Medicine,
Srinakharinwirot University.
Endometriosis
Definition: Ectopic Endometrial Tissue
True Incidence Unknown: ? 1-5%
Does NOT Discriminate by Race
Histology: Endometrial Glands with Stroma
+/- Inflammatory Reaction
Signs and Symptoms
Chronic Pelvic Pain, Dysmenorrhea
Abnormal Uterine Bleeding
Infertility
Deep Dyspareunia
Pelvic Mass (Endometrioma)
Misc: Tenesmus, Hematuria, LBP,
Hemoptysis
Prevalence
Surgical Series (Uncontrolled) 1 – 53%
Surgical Series (Controlled) 23 – 47% (Infertile)
1 – 5% (Fertile)
Population-Based Studies 6.2 –7.9%
Epidemiological Study 0.25 new cases/1000 woman-years
Prevalence = 7.5%
Endometriosis Affects ~5 Million Women,
30-40% are Infertile
Surgical Series (Uncontrolled) 1 – 53%
Surgical Series (Controlled) 23 – 47% (Infertile)1 – 5% (Fertile)
Population-Based Studies 6.2 –7.9%
Epidemiological Study 0.25 new cases/1000woman-years
Prevalence = 7.5%Endometriosis Affects ~5
Million Women, 30-40%are Infertile
Age at Diagnosis
< 19 6%
19 – 25 24%
26 –35 52%
36 –45 15%
> 45 3%
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
Diagnosis
Laparoscopy (“Gold Standard)
Laparotomy
Inconclusive: CA-125, Pelvic Exam,
History, Imaging Studies
Biopsy Preferable Over Visual Inspection
Appearance
Endometriosis May Appear
Brown
Black (“Powderburn”)
Clear (“Atypical”)
Endometriosis May Be Associated with
Peritoneal Windows
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
Pain Management: Medical
Therapy
NSAIDs
OCPs (Continuous)
Progestins
Danazol
GnRH-a
GnRH-a + Add-Back Therapy
Misc: Opoids, TCAs, SSRIs
Continuous OCPs
“Pseudopregnancy” (Kistner)
? Minimizes Retrograde Menstruation
Lower Fertility Rates than Other Medical
Treatments
Choose OCPs with Least Estrogenic
Effects, Maximal Androgenic / Progestin
Effects
Progestins
May be as Effective as GnRH-a for Pain Control
MPA 10-30 mg/day, DP 150 mg Semi-Monthly
May be Taken Long-Term
Relatively Inexpensive
Side-Effects: AUB, Mood Swings, Weight Gain,
Amenorrhea
Danazol
Weak Androgen
Suppresses LH / FSH
Causes Endometrial Regression, Atrophy
Expensive
Side-Effects: Weight Gain, Masculinization,
Occ. Permanent Vocal Changes
GnRH-a
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 )
Surgical Treatment
(Laparoscopy / Laparotomy) Excision/ Fulgeration
Resection of Endometrioma
Lysis of Adhesions, Cul-de-sac Reconstruction
Uterosacral Nerve Ablation
Presacral Neurectomy
Appendectomy
Uterine Suspension (? Efficacy)
Hysterectomy +/- BSO
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
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
Thank you
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