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Endometriosis

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Endometriosis David Blair Toub, M.D. Department of Obstetrics and Gynecology Pennsylvania Hospital Endometriosis Definition: Ectopic Endometrial Tissue True Incidence ... – PowerPoint PPT presentation

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Title: 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 )

16
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

17
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
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