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Endometriose: Que doit savoir
le Gastro - Entérologue ?
Université Paris Descartes,
Sorbonne Paris Cité
Faculté de Médecine, AP-HP,
GHU Ouest, CHU Cochin, Paris, France
Professor Charles Chapron, M.D Head of Department,
Gynecology
Surgical unit: C Chapron, B Borghese, P Santulli,
H Foulot, MC Lafay-Pillet, A Bourret,
G Pierre, A Bititi, P Marzouk, L Marcellin
Medical unit: A Gompel, G Plu-Bureau, L Maitrot
Reproductive Endocrinology unit: D de Ziegler, P Santulli, V Gayet,
I Streuli, FX Aubriot
Intestinal surgery
B Dousset, M Leconte, S Gaujoux
Radiology
AE Millischer
Laboratory: Genetic
D Vaiman, F Mondon, S Barbaux
Laboratory: Imunulogy B Weill, F Batteux, S Chauzenoux
C Nicco, C Chéreau
Laboratory: Reproductive biology JP Wolf, V Lange, K Pocate,
JM Kuntzman, C Chalas
Statistical unit
F Goffinet, PY Ancel
D. de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit,
A. Gompel, Professor and Head, Medical Gynecological unit,
C. Chapron, Professor and Chair, Dpt Gynecology Obstetrics II and Reproductive Medicine
Presence of endometrial
tissue outside of the uterus
DIE
OMA
SUP
A healthcare concern:
1. Prevalence
2. Pain and infertility
3. Cost
Endometriosis: Definitions
Pathogenesis
is poorly
understood
Endometriosis: Clinical appearance
* Superficial OSIS
* Adhesions
* Ovarian endometriomas
* Deep endometriosis
Heterogeneous
disease ++++
Endometriosis: implantation theory
Adenomyosis SUP OMA DIE
SUP, superficial lesion; OMA, endometrioma; DIE, deep infiltrating endometriosis
Deep endometriosis: Definitions
Hum Reprod (2010)
JC Noel (2010)
JC Noel (2010)
Invasion of
the muscularis propria
Endometriosis: Diagnosis process
Onset of
the symptoms
Surgical diagnosis
and treatment
6 to 10 years
17
11 13
7
47
6
0
10
20
30
40
50
1 2 3 4 ≥5 ?
Perc
ent
%
Nb of times doctor seen
Ballweg ML 2004
Endometriosis: Diagnosis process
Nnoaham et al.,
Fertil Steril (2011)
16 centers
10 countries
N = 745 osis
3.3 ± 3.6 years
10.7 ± 9.3 years
Endometriosis: Clinical symptoms
Infertility Pelvic pain
Bleeding
Relationship between endometriosis
and chronic pelvic pain
Pelvic pain
Endometriosis
Symptomatic No pain
symptoms
Adaptated from Hurd Obstet Gynecol (1998)
Endometriosis: Diagnosis process
Sinaii et al., Fertil Steril (2008)
Multi
association
Ballweg ML (2004)
Multi
symptoms
disease
Endometriosis: Diagnosis process
Painful symptoms
related to
menstruation
Endometriosis: Diagnosis process
Ballweg ML (2004)
Onset of symptoms
Adolescents 67.1%
Adults 39.2%
Age of
1st pelvic symptoms
Greene et al., Fertil Steril (2009)
Onset of symptoms Time from seeking
medical attention
to diagnosis
Adolescents 6.0 ± 0.2 years
Adults 2.0 ± 0.3 years
DIE: Importance of questioning
Parameters
No DIE (n = 131)
DIE (n = 98)
p
OR 95% CI
1st degree- relatives
family history of
endometriosis
6
(4.6%)
13
(13.3%)
0.02
3.2
(1.2 - 8.8)
Chapron et al., Fertil Steril (2011)
DIE: Importance of questioning
Parameters
No DIE (n = 131)
DIE (n = 98)
p
OR 95% CI
Absenteism
from school
during
Menstruation
33 (25.2%)
37 (37.7%)
0.04
1.7 (1 - 3)
Chapron et al., Fertil Steril (2011)
DIE: Importance of questioning
Parameters
No DIE (n = 131)
DIE (n = 98)
p
OR 95% CI
Prescription of OCPs
because of severe 1st DM
15 (25.9%) 29 (58.0%) 0.001 4.5 (1.9 - 10.4)
Age (years) 18.1 ± 3.2 16.5 ± 2.4 0.07
Duration of use (years) 5.1 ± 3.8 8.4 ± 4.2 0.02
Chapron et al., Fertil Steril (2011)
DIE: Importance of questioning
Chapron et al., Fertil Steril (2011)
Endometriosis
and oral contraceptives
Chapron et al., Hum Reprod (2011)
OC user SUP * OMAs * DIE *
Never user Reference Reference Reference
Ever user 2.59 (1.11 - 6.03) 1.37 (0.84 - 2.23) 4.2 (1.54 - 11.2)
Current user 2.7 (0.98 - 7.47) 0.95 (0.5 - 1.7) 1.98 (0.65 - 6.07)
Past user 2.56 (1.07 - 6.09) 1.65 (0.99 - 2.75) 5.7 (2.1 - 15.7)
*: Ad OR 95% CI
Deep endometriosis: Rectal wall infiltration
N Se Sp PPV NPV
TRUS
Chapron et al., (2004) 81 97 89 87 98
Bazot et al., (2007) 81 89 93 96 81
Piketty - Chapron (2009) 134 96 100 100 95
MRI
Chapron et al., (2004) 81 76 98 96 85
Abrao et al., (2007) 104 83 98 97 84
Bazot et al. (2007) 88 83 93 96 79
TVUS
Abrao et al. (2007) 104 98 100 100 98
Bazot et al., (2007) 81 93 100 100 87
Piketty – Chapron (2009) 134 90 96 97 89
0
50
100
1er
trim.
3e
trim.
Est
Ouest
NordTRUS
MRI
TVUS
Deep endometriosis: Preoperative diagnosis
Hum Reprod
(2009)
Deeply infiltrating endometriosis: Location: n = 959 patients
Main N Associated lesions Total
lesion USL Va Bl In Ur
R L B
Bladder 75 2 9 6 5 75 97
USL 354 93 175 172 440
Vagina 107 16 22 40 107 185
Intestine 360 59 48 206 201 36 690 1247
Ureter 63 6 13 44 38 13 104 70 288
Total 959 176 267 468 351 124 794 70 2257
Chapron et al., (October 2013) Multifocality +++
Intestinal
endometriosis Anatomic distribution
(n = 413 patients)
Main characteristics N %
Unique without other DIE lesions 41 9.9
Multifocal intestinal DIE lesions 205 49.6
Associated right/left lesions 81 19.6
Bifocal intestinal DIE
MRI: intestinal DIE
Chapron - Dousset (April 2013)
Bowel Deep Endometriosis: Location of microscopic infiltration
(n = 50 patients)
Kavallaris et al., Hum Reprod (2003)
Endometriotic lesions N %
Multifocal (< 2 cm) 31 62
Multicentric ( 2 cm) 19 38
Unicentric and unilocular
0
0
Intestinal
endometriosis Anatomic distribution
(n = 413 patients)
Main characteristics N %
Unique without other DIE lesions 41 9.9
Multifocal intestinal DIE lesions 205 49.6
Associated right/left lesions 81 19.6
Bifocal intestinal DIE
MRI: intestinal DIE
Chapron - Dousset (April 2013)
Severe ureteral
endometriosis Associated DIE lesions
(n = 63 patients)
DIE lesions N % N
USL 41 65.1 63
Vagin 38 63.6 38
Bladder 13 20.6 13
Intestine 53 84.1 104
Ureter 63 100.0 70
Total 63 288
Chapron - Dousset (2013)
Main Patients DIE lesions
4.5 ± 2.5 (range 1 – 17)
Ureteral DIE
is associated
with intestinal DIE
in 84%
Deep endometriosis: Preoperative work-up importance of imaging
TransRectal US MRI
TransVaginal US Kidney scintigraphy
Uro - MRI
Surgery for endometriosis (n = 790 patients)
No (n = 471; 60%) Yes (n = 309; 40%)
SUP 109 (23.1%) 22 (7.1%)
OMA 152 (32.3%) 45 (14.6%)
DIE 210 (44.6%) 242 (78.3%) 4.5
(3.2 - 6.2)
- DIE isolated 144 (68.6%) 138 (57.0%)
- DIE + OMA 66 (31.4%) 104 (43.0%)
Endometriotic
lesions
Previous surgery for Osis OR
95% CI
Sibiude - Chapron et al., Obstet Gynecol (2014)
Surgery for endometriosis (n = 790 patients)
Worst DIE lesion Previous surgery for Osis OR 95% CI
No (n = 471;
60%)
Yes (n = 309; 40%)
USL 71 (34.0%) 32 (13.3)
Vagina 21 (10.0%) 16 (6.7%)
Bladder 18 (8.6%) 17 (7.0%)
Intestine 77 (36.8%) 159 (66.0%) 3.2
(2.1 - 4.8)
Ureter 22 (10.5%) 17 (7.0%)
Sibiude - Chapron et al., Obstet Gynecol (2014)
Surgery for endometriosis (n = 790 patients)
DIE lesion Previous surgery
for endometriosis
OR 95% CI
No (n = 471;
60%)
Yes (n = 309; 40%)
Number
1 - 2 130 (62.2%) 107 (44.2%)
≥ 3 79 (37.8%) 135 (55.8%) 2.1 (1.4 - 3.0)
Mean
number
2.6 ± 1.8 3.1 ± 1.9
< 0.001
Sibiude - Chapron et al., Obstet Gynecol (2014)
Surgery for endometriosis (n = 790 patients)
Endometriotic
lesion
Previous surgery
for endometriosis
OR 95% CI
classification 1 or 2
(n = 263)
≥ 3
(n = 46)
SUP 20 (7.6%) 2 (4.3%)
OMA 45 (17.1%) 0 (0.0%)
DIE 198 (75.3%) 44 (95.7%)
14.4 (2.0 -
106.9)
Sibiude - Chapron et al., Obstet Gynecol (2014)
Coef = 0.62, 95% CI 0.47-0.77, p<0.0001
Nu
mb
er
of
DIE
le
sio
ns
Determinants for existence of DIE: Results with multiple logistic regression analysis
AOR (95% CI) p
Previous surgery (yes vs no) 2.7 (1.7-4.3) <0.001
Previous surgery for endometriosis (n = 790 patients)
Sibiude - Chapron et al., Obstet Gynecol (2014)
Endometriosis: Surgical management
Disease Surgery
Progression
Recurrence
Unnecessary
Inappropriate
?
Obstet Gynecol (2014)
Take home
messages
Strategy
- Multidisciplinary management
Endometriosis
and
Patients
- Global approach
Surgery
Medical Ttt
AR
T
SUP OMAs DIE
Adenomyosis
Pelvic pain
Infertility
Take home
messages
Pelvic pain
Endometriosis Symptoms related to menstruation
Deep endometriosis Pelvic pain intensity
Family history
Adolescent period: absenteism
OC pills prescription for pain
Intestinal DIE Menstrual rectorrhagia
Imaging: 1st TVUS
Mutifocality