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The Modern Management of Endometriosis

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The Modern Management of Endometriosis Malcolm Padwick What is it ? The presence of endometrial tissue outside of the uterine cavity cul-de-sac rectovaginal septum ... – PowerPoint PPT presentation

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Title: The Modern Management of Endometriosis


1
The Modern Management of Endometriosis
  • Malcolm Padwick

2
What is it ?
  • The presence of endometrial tissue outside of the
    uterine cavity
  • cul-de-sac
  • rectovaginal septum
  • surface of rectum
  • fallopian tubes and ovaries
  • uterosacral ligaments
  • bladder
  • pelvic side wall

3
Is it inherited?
  • 6 to 8 fold increase risk in sisters compared to
    unrelated women
  • affected sisters are more likely to have severe
    disease
  • OXEGENE study ongoing
  • ovarian cancer link
  • racial

4
Aetiology
  • Retrograde menstruation
  • tissue transplantation
  • peritoneal cell metaplasia
  • venous spread
  • lymphatic spread
  • immune failure

5
Incidence
  • At sterilisation 2 to 5 have endometriosis
  • 25 to 50 of women investigated for infertility
  • estimated 5 million women in USA
  • 6 to 7 of all females

6
Endometriosis symptoms
  • dysmenorrhoea
  • pelvic pain
  • infertility
  • dyspareunia
  • menstrual irregularities
  • other cyclic bleeding
  • 70
  • 40
  • 35
  • 33
  • 15
  • 1-2

7
Endometriosis
  • Diagnosis
  • laparoscopy

8
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9
The natural progression
  • Lesions
  • Clear mean age 21.5
  • Red
  • Black mean age 31.9
  • disease is progressive in 47 - 64 of women and
    in 20 of treated women (Redwine)

10
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11
Endometriosis and Fertility
  • 30 to 40 of women with endometriosis are
    infertile
  • may be obvious anatomical abnormalities
  • hormonal E2 reduced LH blunted
  • multicystic ovaries
  • Luteinized Unruptured Follicle X 3
  • peritoneal fluid, macrophages, cytokines,
    interferon C3, C4 are all increased
  • plasma embryotoxic in 78 of cases

12
Endometriosis
  • Management options 1
  • Diagnostic laparoscopy
  • Drugs
  • OCP
  • Provera
  • Danazol / Gestrinone
  • GNRH analogues
  • Surgery
  • Hysterectomy with BSO

13
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14
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15
Endometriosis and Fertility
  • Hormonal or antihormonal therapy has no
    beneficial effect
  • on fertility either alone or as an adjunct to
    surgery ( RCOG recommendation)
  • only surgical ablation or excision of disease
    will restore fertility ( RCOG recommendation)

16
Endometriosis
  • Management option 2
  • Diagnostic laparoscopy proceeding to
    immediate corrective surgery LASER and /or
    laparoscopic resection of diseased tissue

17
Endometriosis
  • CO 2 LASER Vs Diathermy
  • depth of destruction
  • accuracy
  • collateral / unseen damage
  • placebo effect
  • cost

18
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19
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20
Pelvic side wall
21
EndometriosisTreatment by CO2 LASER
Classification I minimal II mild III
moderate IV severe AFS
Pregnancies 72 60 50 44
Improved pain 89 87 85 80
Del Pozo 1997
22
Women with pain
  • Drug therapy may relieve inflammation and reduce
    pain in early superficial disease but corrective
    surgery /- drug therapy is preferable (Padwick
    1999)
  • rectovaginal, rectal and uterosacral lesions
    always need surgery
  • endometriomas always need surgery
  • abnormal anatomy and adhesions always need
    surgery

23
Rectal involvement
24
Endometriosis on the caecum
Endometriosis on the caecum
25
Endometrioma
26
LASER ablation of endometriosis
  • endometriosis not cured by medication
  • surgery may cure the younger woman
  • Techniques
  • ablate
  • LUNA
  • resect peritoneum
  • ventrosuspension

27
Before
28
After
29
But what if ?
30
Requirements
  • full RCOG accreditation
  • MAS accreditation
  • surgeon
  • preceptor
  • LASER certification

31
What to expect
  • Overnight stay (98)
  • 3 puncture marks 5mm in length
  • Voltarol / oral analgesics
  • 1 to 2 weeks off work
  • Mostly an immediate difference in pains
  • Benefits of fertility are immediate

32
West Herts Audit
  • 150 women treated per year
  • gt 500 women treated
  • gt 95 diagnostic rate
  • No acute complications
  • No laparotomies
  • One late sepsis
  • Outcome measures ??

33
Conclusion
  • Endometriosis should be treated early and
    aggressively by surgical destruction or
    excision, ideally at laparoscopy. Drug therapy
    which is expensive, largely ineffective and has
    significant side-effects should be reserved for
    selected cases requiring post surgical
    maintenance therapy.
  • Padwick 1999

34
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