Endometriosis

1
Endometriosis

• David Blair Toub, M.D.
• Department of Obstetrics and Gynecology
• Pennsylvania Hospital

2
Endometriosis

• Definition Ectopic Endometrial Tissue
• True Incidence Unknown ? 1-5
• Does NOT Discriminate by Race
• Histology Endometrial Glands with Stroma /-
  Inflammatory Reaction

3
Signs and Symptoms

• Chronic Pelvic Pain, Dysmenorrhea
• Abnormal Uterine Bleeding
• Infertility
• Deep Dyspareunia
• Pelvic Mass (Endometrioma)
• Misc Tenesmus, Hematuria, LBP, Hemoptysis

4
Prevalence
5
Age at Diagnosis
gt 45
lt 19
3
36 45
6
15
19 25
24
26 35
52
6
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

7
Diagnosis

• Laparoscopy (Gold Standard)
• Laparotomy
• Inconclusive CA-125, Pelvic Exam, History,
  Imaging Studies
• Biopsy Preferable Over Visual Inspection

8
Appearance

• Endometriosis May Appear
• Brown
• Black (Powderburn)
• Clear (Atypical)
• Endometriosis May Be Associated with Peritoneal
  Windows

9
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

10
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

11
Pain Management Medical Therapy

• NSAIDs
• OCPs (Continuous)
• Progestins
• Danazol
• GnRH-a
• GnRH-a Add-Back Therapy
• Misc Opoids, TCAs, SSRIs

12
Continuous OCPs

• Pseudopregnancy (Kistner)
• ? Minimizes Retrograde Menstruation
• Lower Fertility Rates than Other Medical
  Treatments
• Choose OCPs with Least Estrogenic Effects,
  Maximal Androgenic / Progestin Effects

13
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

14
Danazol

• Weak Androgen
• Suppresses LH / FSH
• Causes Endometrial Regression, Atrophy
• Expensive
• Side-Effects Weight Gain, Masculinization, Occ.
  Permanent Vocal Changes

15
GnRH-a

• Initially Stimulate FSH / LH Release
• Down-Regulates GnRH ReceptorsPseudomenopause
• Long-Term Success Varies
• Expensive
• Use Limited by Hypoestrogenic Effects
• May be Combined with Add-Back (? gt1 Year )

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Surgical Treatment (Laparoscopy / Laparotomy)

• Excision sí / Fulgeration no!
• Resection of Endometrioma
• Lysis of Adhesions, Cul-de-sac Reconstruction
• Uterosacral Nerve Ablation
• Presacral Neurectomy
• Appendectomy
• Uterine Suspension (? Efficacy)
• Hysterectomy /- BSO

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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

18
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