Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn.
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Transcript of Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn.
Endometriosis
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty Dept of Ob&Gyn
To discover ◦ Endometriosis◦ Endometriosis related condition
To learn◦ Diagnosis of endometriosis◦ Treatment of endometriosis
Objectives
Definition: Ectopic Endometrial Tissue
True Incidence Unknown: ? 1-5%
Histology: Endometrial Glands with Stroma +/- Inflammatory
Reaction
Endometriosis
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/1000w oman-years
Prevalence = 7.5%Endometriosis Affects ~5
Million W omen, 30-40%are Infertile
Asymptomatic. Pain (DYS…….): - Dysmenorrhea (crescendo = progessive) - Dyspareunia. - Dyschesia. - Dysuria.
Chronic Pelvic Pain
Backache. Acute abdomen. Premenst. Tension syndrome.
Abnormal Uterine Bleeding Infertility Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, Hemoptysis
Signs and Symptoms
Uterine= Adenomyosis (50%).
Extraut:- Ovary 30%- Pelvic peritoneum 10%.- F. tube.- Vagina.-Bladder & rectum.- Pelvic colon.- Ligaments.
Pelvic Endometriosis
Age at Diagnosis
< 196%
19 – 2524%
26 –3552%
36 –4515%
> 453%
Sampson: “Retrograde Menstruation” Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the AboveNo Single Theory Explains All Cases of
Endometriosis
Etiology: Theories
Diagnosis of Endometriosis
History (The most important) Symptoms Physical Examination (not much help) Serum Markers (Lacks sensitivity) Ultrasound (of little value except endometrioma) Magnetic Resonance Imaging (MRI) (a good guess!) Other Imaging Modalities
◦ immunoscintigraphy and positron emission tomography Transvaginal Hydrolaparoscopy Laparoscopic Visualization of the Pelvis (The gold
standard)◦ Biopsy Preferable Over Visual Inspection
Novel Diagnostic Test
Rule out other Causes of Symptoms (The next most important)
Laparoscopy (“Gold Standard)
Laparotomy
Inconclusive: CA-125, CA-199Pelvic Exam,
History, Imaging Studies
Biopsy Preferable Over Visual Inspection
Diagnosis
Endometriosis May AppearBrownBlack (“Powderburn”)Clear (“Atypical”)
Endometriosis May Be Associated with Peritoneal Windows
Appearance
ENDOMETRIOSIS AND ADOLESCENCE
Variety of endometriotic lesions seen at laparoscopy
Endometriosis-Peritoneal
0varian endometriosis
ENDOMETRIOSIS AND ADOLESCENCE
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.
Revised AFS 1985
Stage I (minimal) 1 – 5Stage II (mild) 6 – 15Stage III (moderate) 16 – 40
Stage IV (severe) > 40
Endometriozis-Evreleme
EVRE-1 (minimal= 1-5) EVRE-2 (hafif = 6-15)
EVRE-3 (orta = 16-40) EVRE-4 (ağır = > 40)
Recognize Goals: – Pain Management– Preservation / Restoration of Fertility
Discuss with Patient:– Disease may be Chronic and Not Curable– Optimal Treatment Unproven or
Nonexistent
Treatment: Overall Approach
NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Misc: Opoids, TCAs, SSRIs
Pain Management: Medical Therapy
“Pseudopregnancy” (Kistner) ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical
Treatments Choose OCPs with Least Estrogenic Effects,
Maximal Androgenic / Progestin Effects
Continuous OCPs
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
Progestins
Weak Androgen Suppresses LH / FSH Causes Endometrial Regression, Atrophy Expensive Side-Effects: Weight Gain, Masculinization,
Occ. Permanent Vocal Changes
Danazol
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 )
GnRH-a
Excision Yes / Fulgeration No!
Resection of Endometrioma
Lysis of Adhesions, Cul-de-sac Reconstruction
Uterosacral Nerve Ablation
Presacral Neurectomy
Appendectomy
Uterine Suspension (? Efficacy)
Hysterectomy +/- BSO
Surgical Treatment (Laparoscopy / Laparotomy)