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Endometriosis

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More common in Monozygotic twins than in Dizygotic twins Simpson et al, 1984 ... Adverse effects: weight gain, abnormal bleeding & HTN. Endometriosis. GnRH agonists ... – PowerPoint PPT presentation

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Title: Endometriosis


1
Endometriosis
  • Dr. Hima Kandimalla
  • Mount Hope Womens Hospital
  • Trinidad Tobago

2
Endometriosis
  • Presence of endometrial glands stroma outside
    the endometrial cavity and uterine musculature

3
Endometriosis
  • Epidemiology
  • Globally 90 million suffering with Endometriosis
  • Prevalence 3-10 of reproductive age group
    25-35 of infertile women
  • Peak incidence 30-45 yrs of age
  • Prevalence is similar in all races

4
Endometriosis
  • sites

5
Endometriosis
  • Pathogenesis
  • Implantation or Metastatic theory - Sampson, 1927
  • Retrograde menstruation
  • More common in young girls with
  • genital outflow obstruction
  • Physiological phenomenon
  • Halme et al, AJOG, 1984

6
Endometriosis
  • Retrograde menstruation
  • ? Contributing factors
  • 1. Alteration in the Endometrium
  • 2. Altered Immune response
  • 3. Favorable Peritoneal environment
  • Mechanical Endometriotic foci in surgical scars
  • Lymphatic or Hematogenous Extragenital locations

7
Endometriosis
  • Metaplasia theory Meyer, 1919
  • Metaplastic changes in coelomic membrane towards
    endometrial like tissue following prolonged
    irritation or Oestrogen stimulation

8
Endometriosis
  • Genetic, Immunological environmental factors
  • 7 times more common in 1relatives
  • Halme et al, 1986 Sampson et al 1980
  • More common in Monozygotic twins than in
    Dizygotic twins Simpson et al, 1984
  • Decreased cellular immunity to endometriotic
    tissue - Dmowski et al, 1981
  • ? Dioxins Endometriosis association, 1993

9
Endometriosis
Mechanical
Immunological
Genetic
Endocrine
Implantation
Metaplasia
Endometrial implant
Progression invasion
Lymphatic Blood spread
Adapted Modified from R.W. Shaw, Gynecology
10
Endometriosis
  • Pathology
  • Puckered black lesions
  • White scarring
  • Red polyps
  • Clear blebs

11
White plaques Clear vesicles
Blue-black lesions
Newly formed blood vessels
12
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13
Endometriosis
  • Pathology
  • Endometrioma
  • Contains blood, fluid menstrual debris
  • Brown to black color due to Hemosiderin

14
Endometriosis
  • Pathology
  • Microscopy
  • Endometrial glands stroma
  • Often contain fibrous tissue, blood cysts

15
Endometriosis
  • Stromal endometriosis
  • Implants contain only stromal component without
    glandular part
  • Not hormonal dependent
  • Locally malignant

16
Endometriosis
Staging American society of Reproductive
Medicine, 1996
Stage I Minimal Isolated superficial
implants, No adhesions
Stage II Mild More superficial implants (lt5cm),
No significant adhesions
17
Endometriosis
Staging American society of Reproductive
Medicine, 1996
Stage III Moderate Multiple superficial
invasive implants, Peritubal Periovarian
adhesions may be present
Stage IV Severe Multiple implants, Ovarian
endometriomas, Many dense adhesions
18
Endometriosis
Staging American society of Reproductive
Medicine, 1996
  • Staging is designed to predict the likelihood of
    future fertility
  • There is no correlation between the stage of
    disease the degree of pain or the prognosis
    with treatment

19
Endometriosis
  • Diagnosis
  • Often misdiagnosed
  • The average time to diagnosis is 9.28 years
  • Endometriosis association study, 1998
  • Delay in diagnosis
  • - Progression of symptoms
  • - ? Infertility till complete reproductive
    failure

20
Endometriosis
Symptoms
  • Reproductive organs
  • Dysmenorrhoea
  • Lower abdominal, pelvic low back pain
  • Menstrual irregularities
  • Infertility

21
Endometriosis
Symptoms
  • GIT
  • Cyclical rectal bleeding
  • Tenesmus
  • Dyschesia
  • Diarrhea/ Cyclic constipation
  • Image courtesy of Dr. Andrew Cook. Visit his
    site Endometriosis

22
Endometriosis
Symptoms
  • Urinary tract
  • Cyclical hematuria
  • Cyclical dysuria
  • Ureteric obstruction

23
Endometriosis
Symptoms
  • Lungs
  • Cyclical hemoptysis
  • Blood stained Pleural effusions
  • Catamenial Pneumothorax

Haemothorax ascites associated with
endometriosis.- Charran D, Roopnarinesingh
S.Department of Obstetrics and Gynaecology,
U.W.I., Trinidad.West Indian Med J. 1993
Mar42(1)40-1.
24
Endometriosis
Symptoms
  • Umbilicus Surgical scars
  • Cyclical pain swelling

25
Endometriosis
Symptoms
26
Endometriosis
  • Signs
  • Pelvic tenderness.
  • Fixed retroverted uterus.
  • Nodularity of the Douglas pouch and uterosacral
    ligaments.
  • Ovaries may be enlarged and tender . Ovarian cyst
    may be detected.

27
Endometriosis
  • Infertility
  • Clear association with infertility has not been
    established
  • Incidence of endometriosis in general population
    of reproductive age 2-10
  • - Barbieri et al, 1990
  • Incidence of endometriosis in infertile women
    20-40
  • Mahmood et al, 1990

28
Endometriosis
  • Infertility
  • In early stages
  • ? Activated macrophages in peritoneal fluid
  • ? PG, IL-1, TNF proteases in peritoneal fluid
  • ? levels of anti-endometrial antibodies
  • Luteal phase dysfunction
  • Abnormal follicle growth
  • Multiple premature LH surges
  • LUF syndrome

29
Endometriosis
  • Infertility
  • In advanced stages
  • Pelvic adhesions impairs ova release, blocks
    sperm entry into the peritoneal cavity inhibits
    tubal pickup of the oocyte

30
Endometriosis
  • Risk of cancer
  • Ovarian Clear cell Endometrial cell carcinomas
  • Breast cancer, Melanoma NHL
  • - Endometriosis Association study, 1998

31
Endometriosis
  • Differential diagnosis
  • Pelvic infection
  • Uterine Myomas
  • Ovarian malignant tumors with metastatic deposits
    in the pouch of Douglas
  • Acute abdomen
  • Rectal carcinoma

32
Endometriosis
Investigations Laparoscopy Gold standard
diagnostic test for endometriosis It permits a
see treat approach, although its
effectiveness may be limited by the nature of the
disease and the surgeon's skill
33
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34
Endometriosis
  • Investigations
  • Serum CA 125
  • Sensitivity 28 specificity 90
  • - Mol BW et al, Fertil Steril, 1998
  • Not useful for screening, because of poor
    sensitivity
  • Can be used to identify a sub-group of women who
    are likely to benefit from early laparoscopy to
    follow the progress of disease after establishing
    the diagnosis

- Cheg YM et al, Obst Gyn, 2002
35
Endometriosis
Investigations Ultrasound Sensitivity for focal
endometrial implants is poor
36
Endometriosis
  • Investigations
  • Ultrasound
  • For Endometriomas sensitivity 83 specificity
    98

37
Endometriosis
  • Investigations
  • CT scan
  • Endometriomas may appear solid, cystic or mixed
  • Because of poor specificity high radiation, CT
    has been replaced by MRI

38
Endometriosis
  • Investigations
  • MRI
  • Role is limited in visualizing small
    endometriotic implants and adhesions
  • More useful for lesions in extraperitoneal
    locations the contents of pelvic mass
  • More frequently used in staging treatment
    response monitoring

39
Endometriosis
  • Treatment
  • Consider
  • Age
  • Symptoms
  • Stage
  • Infertility

40
Endometriosis
  • Treatment
  • Rationale
  • Recognize Goals
  • Pain Management
  • Preservation / Restoration of Fertility
  • Discuss with Patient
  • Disease may be Chronic and Not Curable
  • Optimal Treatment Unproven or Nonexistent

41
Endometriosis
  • Lines of management
  • Expectant
  • Medical
  • Hormonal
  • Surgical

42
Endometriosis
  • Expectant management
  • Young , asymptomatic infertile patient with mild
    endometriosis.
  • If pregnancy does not achieved within 12 - 18
    months of observation, hormonal or surgical
    treatment is indicated .

43
Endometriosis
  • Medical Treatment
  • Symptomatic pts with minimal or mild lesions
  • NSAIDs
  • Opioids.

44
Endometriosis
  • Hormonal Treatment
  • Produces pseudo pregnancy or pseudo menopause
  • Danazol
  • Progestins
  • Gestrinone
  • Combined oestrogen-progestogen Pills
  • GnRH agonists.

45
Endometriosis
  • Hormonal Treatment
  • Indications
  • Small superficial lesions
  • Recurrence after conservative surgery
  • Preoperative for 6-12 wks to decrease size
  • Postoperative for residual lesions
  • When surgery is contraindicated or refused by the
    patient.
  • Enometriosis in Rectovaginal septum laparotomy
    scars doesnt respond to Hormonal therapy

46
Endometriosis
  • Danazol
  • Isoxazole derivative of 17 alpha ethinyl
    testosterone
  • Causes anovulation by
  • Attenuating the mid cycle surge of LH
  • Inhibiting multiple enzymes in steroidogenic
    pathway
  • ? Testosterone levels
  • Dose 400 800 mg/ day for 6 months
  • Adverse effects Androgenic effects, effects on
    serum lipids, ? Bone mineral density Liver
    damage

47
Endometriosis
  • Progestational drugs
  • Causes endometrial decidualization atrophy
  • Medroxyprogesterone (Provera) is commonly used
  • Dose 20-30 mg/ day for 6 -9 months
  • Adverse effects Abnormal uterine bleeding,
    nausea, breast tenderness, fluid retention
    depression

48
Endometriosis
  • Gestrinone (Ethylnorgestrienone)
  • Antiprogestational steroid causes ? estrogen
    progesterone receptors
  • Dose 5-10 mg/ wk - dly or twice a wk or 3 times
    a wk, for 6-9 months
  • Adverse effects deepening of voice, hirsuitism
    Clitorial hypertrophy

49
Endometriosis
  • Combined pills
  • Well tolerated can be continued for long term
  • 1 pill/ day either continuously or cyclically
  • Continuous regimen is superior in patients with
    dysmenorrhea
  • Adverse effects weight gain, abnormal bleeding
    HTN

50
Endometriosis
  • GnRH agonists
  • ? FSH LH results in endometrial atrophy
    amenorrhea
  • Intranasally or SC or IM with a frequency of
    twice dly to once in 3 months up to 3 - 6 months
  • Adverse effects transient vaginal bleeding, hot
    flushes, vaginal dryness, ? libido, breast
    tenderness, insomnia, depression, irritability,
    fatigue, headache, osteoporosis, ?
    elasticity of skin
  • GnRH agonists Add-back therapy (estrogens
    progestogen) less side-effects but with same
    efficacy, can be continued beyond 6 months

51
Endometriosis
Hormonal Treatment The choice between the
COCPs, Progestogens, Danazol GnRH agonists
depends principally upon their side-effect
profiles because they relieve pain associated
with endometriosis equally well - Clinical Green
Top Guidelines, 2000
52
Endometriosis
  • Surgical management
  • Conservative Excision, Cauterization
    Evaporation
  • Surgeries for pain - Uterosacral Nerve Ablation
    (LUNA), Presacral Neurectomy
  • Radical surgeries - Hysterectomy /- BSO
  • Surgeries for Endometrioma Cystectomy, Drainage
    coagulation, Fenestration

53
Endometriosis
  • Surgical management
  • Laparotomy Vs Laparoscopy
  • Efficacy is same
  • Laparoscopy less cost shorter recovery time
    even in women with advanced endometriosis

54
Endometriosis
  • Laparoscopic management
  • 1. Excision
  • 2. Vaporization
  • 3. Fulguration Desiccation
  • 4. Cystectomy for endomterioma
  • 5. Drainage Coagulation for endometrioma
  • 6. Fenestration for endometrioma
  • No RCTs available to compare these procedures
  • Cystectomy offer better results than drainage
    coagulation for Endometrioma
  • If no cyst wall is present, Fenestration followed
    by GnRH agonists may prove beneficial

55
Endometriosis
Laparoscopic management
56
Surgical management
  • outcome was poorest in minimal endometriosis
  • much better in moderate severe cases
  • - Sutton CJ et al, Fertil Steril 1994

57
Endometriosis
  • Combination of Hormonal Surgical
  • Postoperative Danazol Medroxyprogesterone for 6
    months lowered the pain scores significantly
    Telimaa S et al, Gynecol Endo, 1987
  • Postoperative GnRH agonist for 6 months lowered
    the recurrence rates but with no change in pain
    scores Parazzini F et al, AJOG, 1994
  • Sufficient data is not available to conclude that
    hormonal surgical combination is associated
    with significant benefits. The possible benefits
    should be weighed in the context of the adverse
    effects costs of these therapies
  • - Cochrane review, May 2004

58
Endometriosis
  • Infertility Management
  • No role for medical therapy with hormonal drugs
  • Laparoscopic ablation of minimal mild
    endometriosis may improve fertility rates
  • - Cochrane review, 2004

59
Endometriosis
  • IUI
  • The presence of endometriosis does not generally
    impair the results of IUI
  • Ovarian hyperstimulation using Gonadotrophins
    with IUI is better than no treatment or IUI alone
  • Nulsen Jc et al, Obst Gyn, 1993
  • Tummon IS et al, Fertil Steril, 1997

60
Endometriosis
  • Treatment

Pelvic pain suspected Endometriosis
Continue drug therapy
NSAID or OCP
Success
Failure
Empirical GnRH agonist Estro Prog add-back
therapy
Operative Laparoscopy
Continue Drug therapy
Failure
Success
GnRH agonist Estro Prog add-back therapy
61
Endometriosis
  • Treatment

Infertility Suspected endometriosis
Operative Laparoscopy
Assisted Reproduction
Watchful waiting
Success
Pregnancy
Failure
62
Endometriosis
  • Conclusion
  • Endometriosis is a mystery tour as it requires
    decision making at every stage by the physician
    and the patient.
  • Endometriosis still stand as one of the
    most-investigated disorders in gynecology. So is
    one of the highest priorities for research.

63
Thank you
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