ATYPICAL ENDOMETRIOSIS

BYMAGDY ABDELRAHMAN MOHAMED

Lecturer of OB/GYN2016

Nomenclature:Atypical endometriosis. Subtle endometriosis.Non pigmented endometriosis

Defenition Endometriosis: the presence of functional

endometrium outside the uterine cavity.

Atypical (Subtle) endometriosis: Endometriotic lesions that lack the typical black-blue, powder-burn appearance.

(Jansen & Russel,1986)

Typical lesions (A): Black or bluish lesions:

It results from tissue bleeding and retention of blood pigment.

(B) Red lesions.

Red flame-like lesions, glandular excrescences and subovarian adhesions.

SUBTLE LESIONS I- RED lesions:

Red flame-like lesions: more commonly affecting the broad ligament & uterosacral ligaments.

Glandular excrescences resemble the mucosal surface of the endometrium.

Areas with hypervascularization.

Typical lesion

II- White lesions: White opacification: appears as peritoneal scaring or as

circumscribed patches often thickened & sometimes raised.Subovarian adhesions. Yellow-brown peritoneal patches resembling café au lait

patches. Circular peritoneal defects: frequently occur in areas of the

pelvis which overlie loose connective tissue.

Non-visible endometriosis Biopsies were taken from visually normal

peritoneum of the uterosacral ligaments. Histological study revealed the presence of

endometriotic tissue in about 6% of infertile women without endometriosis.

Nezhat F et al, 1991, Walter AJ et al, 2001.

Subtle endometriosis SE are more common than the classic

lesions in the adolescents with pelvic pain (Davis et al,1993).

The incidence decreases with age (Konincks et al,1991).

Biological activity Subtle endometriosis are thought to be more

biologically active than typical forms. The red petechial implants produce twice the

amount of PGF than brown lesions, which in turn produce more PGF than typical powder-burn implants.

Clinical picture1. Infertility.

2. Pain: Dysmenorhea,. Dysparunia. Chronic pelvic pain.

Clinical picture Infertility.

SE is the most common single cause of unexplained infertility.

(Propst & Laufer,1999 .)

Clinical picture Pain.

Endometriosis occurs in approximately 70% of adolescent girls with chronic pelvic pain not responding to conventional medical therapy and the majority of patients have stage I disease.

(Ivo Brosens et al, 2013)

Diagnosis Standard laparoscopy.

Negative laparoscopy results do not mean that the patient has no E (Martin,1999)

Laparoscopy under hydroflotation:Using lactated Ringer or normal saline introduced

into the pelvis (Laufer,1997).

Diagnosis Transvaginal hydrolaparoscopy:

Superior to standard laparoscopy for detection of Subtle endometriotic adhesions of the ovary .

Histopathologic examination: Biopsy taken from suspected lesions.

Differential diagnosis Hemangiomas. Old suture. Reaction to oil-contrast medium. Epithelial inclusions. Secondary breast & ovarian cancer.

Differentiation between SE & above lesions may be impossible visually but may be achieved histologically

TREATMENT Aim of treatment:

Reduce pain.Increase the possibility of pregnancy.Delay recurrence for as long as

possible.

Ideal Goal ASRM recommendation.

“Endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures.” Fertil & Steril, 2008

ADVANCES IN TREATMENT

Dienogest (Visanne) Synthetic oral progestogen with unique

pharmacological properties. highly selective for the progesterone

receptor .

Unique Strong progestational effects Moderate antigonadotrophic effects No androgenic, glucocorticoid or

mineralocorticoid activity.

Dienogest 2mg once-daily. Can start at any day of menstrual

cycle. Must be continued regardless of

vag. Bleeding.

Advantages Dienogest appears to be safe and effective

when taken for up to 2 years. Dienogest is an oral therapy. Treatment of endometriosis with dienogest

is not inferior to that with GnRH agonists.

Mirina ( LNG-IUD) Treatment of choice for endometriosis

associated pain in women who do not wish to conceive. Effective for at least 5 ys.Can be reapplied every 5 ys.No modifications in estrogen levels.Low-cost therapy.Fewer side effects than other progestogenic

agents.

Aromatase inhibitors Idea of use:

In Normal endometrium: No detectable levels of aromatase activity

In endometriosis: An increased expression

of cytochrome P450 aromatase in endometrial tissue.

Aromatase inhibitors Disadvantages:

CostOsteoporosis {decrease E in local

tissues}. Controversial

Selective Progesterone receptor modulators (SPRM) Asoprisnil.

It reduce pelvic pain as well as dysmenorrhea.

Its effect on bleeding pattern is dose-dependent. (Chwalisz et al, 2004).

Advantage: No estrogen deprivation.

Angiogenesis inhibitors Statins:

Inhibit the growth of human endometrial stromal cells in vitro (Piotrowski et al, 2006).

Thalidomide (angiostatic & Immunomodulatory): Effective in women with relapsing endometriosis

(Scarpellini et al, 2002).

Atosiban