EndometriosisENDOMETRIOSIS

Is characterized by the presence of endometrial tissue on the ovaries, fallopian tubes or other sites, causing pain or infertility. The disease tends to progress under the repetitive influence of the menstrual cycle I

Dense adhesions are commonly associated with advanced endometriosis. They can be treated with laparoscopy techniques, but are more likely to reform after surgery.

Minimal adhesions between the left ovary and pelvic sidewall. Commonly associated with mild to moderate endometriosis.

This picture shows a chocolate cyst, which can be quite common in more advanced endometriosis

Rupture endometrioma

Endometriosis! Epidemiology > 70 million women and girls have Endometriosis world-wide. 10 - 20 % of women of reproductive age have Endometriosis. It is more common than breast cancer or Aids, and many other diseases, that are well known Endometriosis is not usually fatal

the longer that this disease goes undiagnosed the more damage it can do.

Pathogenesis is not well understoodis probably multifactorial in originthe most widely embraced theory involves retrograde menstruation5Retrograde menstruation

InvestigationA definitive diagnosis can be made only by means of laparoscopyImaging tests: ultrasound, MRI, CT, are occasionally used to identify individual lesions Biochemical markers CA-125 A recent study of this antigen level, showed it to be high in 90 percent of women with Endometriosis

Stages of EndometriosisBased on the severity, location, amount, depth and size of growths.

The stages of the disease do not indicate the level of pain, infertility or symptoms. the correlation between stage and extent of disease remains controversial

Stages of EndometriosisStage 1 - minimal disease, superficial and filmy adhesions Stage 2 - mild disease, superficial and deep endometriosis Stage 3 - moderate disease, deep endometriosis and adhesions Stage 4 - severe disease, deep endometriosis, dense adhesion

Classification of Endometriosis(Modified American Fertility Society System)Base on extent of peritoneum,ovary,tube,cul de sac endometriosis and adhesionsStage IScore 1-5 minimalStage IIScore 6-15 mildStage IIIScore 16-40 moderateStage IVScore > 40 Severe

Classification of Endometriosis

Classification of Endometriosis

Common site of endometriosis

Endometriosis SymptomsEndometriosis does not follow any distinct pattern The symptoms of Endometriosis vary from one woman to another The most common symptom is pelvic pain.

The most common symptomsPain before and during periods Pain with intercourse General, chronic pelvic pain throughout the month Heavy and/or irregular periods Painful urination during menstruation Infertility Fatigue Low back pain Painful bowel movements, especially during menstruation Diarrhoea or constipation

Symptoms relate to endometriosis siteReproductive Endometriosis Pelvic painEctopic (tubal) pregnancy Dysmenorrhea Infertility Miscarriage(s) Painful ovulationUterosacral/Presacral Nerve EndometriosisBackache Leg pain DyspareuniaCul-de-sac ("Pouch of Douglas") EndometriosisDyspareunia (pain during intercourse) Gastrointestinal symptoms Pain after intercourse

Gastrointestinal symptoms of Endometriosis Nausea Diarrhea Blood in stool Bloating Vomiting Rectal pain Rectal bleeding Tailbone pain Abdominal cramping Constipation Sharp gas pains Painful bowel movements

Symptoms relate to endometriosis site

Urinary tract EndometriosisBlood in urine Painful or burning urination Hypertension Tenderness around the kidneys Flank pain radiating toward the groin Urinary frequency, retention, or urgencySymptoms relate to endometriosis site

Pleural (lung & chest cavity) Endometriosis Very occasionally Coughing up of blood or bloody sputum, particularly coinciding with menses Accumulation of air or gas in the chest cavity Constricting chest pain and/or shoulder pain Collection of blood and/or pulmonary nodule in chest cavity (revealed under testing) Shortness of breathSymptoms relate to endometriosis site

Symptoms relate to endometriosis siteSkin Endometriosis Painful nodules, often visible to the naked eye, at the skin's surface. Can bleed during menses and/or appear blue upon inspection. Sciatic EndometriosisHip painpain that radiates from the buttock and down the leg

Differential diagnosis by symptomsGeneralized pelvic pain Pelvic inflammatory diseaseEndometritisSexual or physical abuseNeoplasms, benign or malignantOvarian torsionPelvic adhesionNongynecologic causes

Differential diagnosis by symptoms Dysmenorrhea Primary Secondary (adenomyosis, myomas, infection, cervical stenosis)

Differential diagnosis by symptoms Dyspareunia Musculoskeletal causes (pelvic relaxation, levator spasm) Gastrointestinal tract (constipation, irritable bowel syndrome) Urinary tract (urethral syndrome, interstitial cystitis) Infection Pelvic vascular congestion

Differential diagnosis by symptoms Infertility Male factor Tubal disease (infection) Anovulation Cervical factors (mucus, sperm antibodies, stenosis) Luteal phase deficiency

Treatment options for Endometriosis There are general points which should be taken into consideration The severity of the symptoms The type of symptoms The age of the patient The desire to get pregnant or not Length of treatment Coping with side-effects of drug treatment Cost

Treatment optionsObservation with no medical intervention Hormone treatment Surgery Combined treatment

Drugs Commonly used GnRH agonists inhibit the secretion of gonadotropin a complete block of egg development, estrogen production and menstrual cycle, makes 'menopausal' Danazol is a mild form of the male hormone testosterone inhibits leuteinizing hormone (LH) and follicle-stimulating hormone (FSH) Gestrinone It works in much the same way as danazol with similar, but milder, side effects Contraceptive pill suppress LH and FSH and prevent ovulation Progestational Agents Depo-ProveraProgesterone hormone tablets The Mirena Coil (IUD with Levonorgestrel )

GnRH agonists

Gonadotropin-releasing hormone agonistleuprolide (Lupron, Eligard) buserelin (Suprefact, Suprecor) nafarelin (Synarel) histrelin (Supprelin) goserelin (Zoladex) deslorelin (Suprelorin, Ovuplant)

GnRH antagonist Abarelix (Plenaxis) Cetrorelix (Cetrotide), by SeronoGanirelix (Antagon), by Organon International

SurgeryDefinitive surgery, which includes hysterectomy and oophorectomy, is reserved for use in women with intractable pain who no longer desire pregnancy.In less severe cases, one ovary may be retained to preserve ovarian function

Surgical treatment

Surgical Treatment

Surgical vs. Medical Treatment of Endometriosis

TreatmentAdvantagesDisadvantages

SurgicalBeneficial for infertilityExpensivePossibly better long-term resultsInvasiveDefinitive diagnosisOption for definitive treatmentMedicalDecreased initial costAdverse effects commonEmpiric treatmentUnlikely to improve fertilityEffective for pain relief

Recurrence Rates a laparoscopically defined cumulative five-year recurrence rate of about 19 percent. the long-term benefit of surgical intervention for pain is enhanced by definitive surgery, including bilateral oophorectomy, with a 10 percent cumulative recurrence after 10 years.surgical treatment is the apparently lower recurrence rate compared with medical treatment