Endometriosis - PowerPoint PPT Presentation

Loading...

PPT – Endometriosis PowerPoint presentation | free to download - id: 71bd14-MDhiM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Endometriosis

Description:

Title: Visanne Slide Deck 1 Last modified by: reception Created Date: 9/16/2009 9:34:47 AM Document presentation format: On-screen Show (4:3) Other titles – PowerPoint PPT presentation

Number of Views:83
Avg rating:3.0/5.0
Slides: 53
Provided by: coz46
Learn more at: http://endpain.co.za
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Endometriosis


1
Endometriosis
  • The Disease
  • Definitions and Epidemiology
  • Aetiology
  • Symptomatology
  • Diagnosis
  • Laparoscopy
  • Laparoscopic Images
  • The Outlook

2
Endometriosis (continued)
  • Treatment
  • Current Treatment Options
  • Non-specific Therapies
  • Specific Therapies
  • Progestins
  • Danazol
  • GnRH Agonists
  • Surgery
  • Guidelines
  • Summary

3
Endometriosis The Disease
  • Definitions and Epidemiology

4
Definitions
  • The presence of endometrial-like tissue outside
    the uterus induces a chronic, inflammatory
    reaction1
  • Endometriosis derived from ancient Greekendo -
    inside and metra - womb
  • found predominantly in women of reproductive
    age, from all ethnic and social groups1
  • associated symptoms can impact on general
    physical, mental and social well-being1
  1. Kennedy S, Berggvist A, Chapron C et al. Hum
    Reprod 2005.

5
Epidemiology
  • Endometriosis is a prevalent condition
  • 510 of the female population1,2
  • 5.5 million women in USA 16 million in Europe3
  • Affects women during reproductive years
  • Younger age at onset predicts more severe
    disease4
  • 50 in women with dysmenorrhea 75 in women
    with pelvic pain 2540 in infertile/subfertile
    women5,6
  1. Mounsey AL et al. Am Fam Phys 2006
  2. Eskenazi B Warner ML. Obstet Gynecol Clin North
    Am 1997
  3. Taylor MM AORN 2003
  1. Ballweg ML et al. J Pediatr Adolesc Gynecol
    2003
  2. Child TJ et al. Drugs 2001
  3. Cramer DW et al. Ann N Y Acad Sci 2002.

6
Endometriosis The Disease
  • Aetiology

7
Sites Commonly Affected
  • Extent of disease varies from a few, small
    lesions on otherwise normal pelvic organs to
    large, ovarian endometriotic cysts
    (endometriomas),and/or extensive fibrosis and
    adhesion formation causing markeddistortion of
    pelvic anatomy1
  • Pelvic cavity
  • Peritoneum, ovaries,pouch of Douglas,uterosacral
    ligaments
  • Other sites
  • Vagina, bowel, bladder, ureters
  • Rare sites
  • Lungs, brain
  1. Kennedy S, Berggvist A, Chapron C et al. Hum
    Reprod 2005.

8
Critical Aspects of Pathogenesis
  • Endometrial-like cells attach to peritoneal
    tissue/other sites
  • Cellular infiltration/invasion, involving
    angiogenesis
  • Cellular proliferation
  • Inflammation which can cause
  • Nerve irritation
  • Adhesions
  • Individual variation

Mahutte NG, Kayisli U, Arici A. Endometriosis in
Clinical Practice. 2005 Fraser IS. J Hum Reprod
Sci 2008.
9
Risk Factors
  • Pathophysiology unclear
  • Certain characteristics lead to
    increased/decreased risk

Increased Risk Decreased Risk
Increased exposure to endometrial material short menstrual cycles, heavy/longer bleeding, early menarche, late menopause1,2 Increased number of live births1
Family history3 Longer duration of lactation1
Low exercise4-6
  1. Mounsey AL et al. Am Fam Phys 2006
  2. Missmer SA et al. Obstet Gynecol 2004
  3. Bischoff F et al. Ann N Y Acad Sci 2004
  1. Eskenazi B et al. Obstet Gynecol Clin North Am
    1997
  2. Cramer DW et al. Ann N Y Acad Sci 2002
  3. Hediger ML et al. Fertil Steril 2005.

10
Endometriosis The Disease
  • Symptomatology

11
Symptomatology
  • Typical symptoms
  • Dysmenorrhea
  • Premenstrual pain
  • Dyspareunia
  • Diffuse/chronic pelvic pain
  • Other symptoms
  • Perimenstrual symptoms(e.g. bowel- or
    bladder-associated)
  • Back pain
  • Chronic fatigue
  • Significant proportion of cases asymptomatic
  • Diagnosis based on symptoms alone can be
    difficult
  • Variable presentation
  • Similar to other conditions irritable bowel
    syndrome,pelvic inflammatory disease

Sinaii N, Plumb K, Cotton L et al. Fertil Steril
2008.
12
Prevalence and Overlap of Symptoms
Pelvic pain dysmenorrhea 25.2
Dysmenorrhea only 12.7
Pelvic pain only 6.5
Dyspareunia pelvic pain dysmenorrhea 34.4
Pelvic pain dyspareunia 3.3
Dysmenorrhea dyspareunia 6.5
Dyspareunia only 0.7
Sinaii N, Plumb K, Cotton L et al. Fertil Steril
2008.
10.7 of women did not report any gynecologic
pain symptoms.
13
Infertility
  • Endometriosis is frequently associated with
    infertility
  • 3040 experience subfertility or infertility
  • Lesions cause chronic inflammation/adhesions,
    impacting fertility
  • Infertility may be the sole presenting symptom
  • 2540 of infertile women have endometriosis
  • Endometriosis may be diagnosed by chance by an
    infertility specialist

Ozkan S, Murk W, Arici A. Ann NY Acad Sci 2008.
14
Natural History of Disease
  • Highly variable and difficult to predict in
    individual women
  • Progressive course characterised by worsening of
    pain1
  • Younger onset age predicts more severe disease
    course2
  • Spontaneous regression is possible3
  1. Koninckx PR, Meuleman C, Demeyere S et al. Fertil
    Steril 1991
  2. Ballweg J Pediatr Adolesc Gynecol 2003
  3. Mahmood TA, Templeton A. Hum Reprod 1990.

15
What is the Impact of Endometriosis?
Morbidity Absenteeism Socio-economic cost

Quality of life Educational opportunities Daily
function Self-esteem Fertility
Mounsey AL, Wilgus A, Slawson DC. Am Fam Phys
2006 Gao X, Yeh YC, Outley J et al. Curr Med Res
Opin 2006.
16
Endometriosis Diagnosis
17
Diagnosis
Diagnosis often delayed (average 8.3 years1)
Typical clinical symptoms and signs(e.g.
uterosacral nodularity)2,3
Suggestive
Laparoscopic visualisation ideally with
confirmatory histology1
Magnetic resonance imaging and ultrasound4
Laboratory tests currently fail to show
predictive value5,6 New semi-quantitative
procedures being assessed7
Definitive
New techniques
  1. Kennedy S, Bergqvist A, Chapron C, et al. Hum
    Reprod 2005
  2. Mounsey AL, Wilgus A, Slawson DC. Am Fam Phys
    2006
  3. Matorras R, Rodríguez F, Pijoan JI, et al. Am J
    Obstet Gynecol 1996
  1. Bazot et al. J Minim Invasive Gynecol 2005
  2. Bedawy et al. Clin Chem Acta 2004
  3. Matalliotakis et al. Arch Gynecol Obstet 2005
  4. Fraser et al. J Hum Reprod Sci 2008.

18
Diagnostic Pathway
19
Typical Symptoms
  • Dysmenorrhea
  • Most commonly reported symptom
  • Severe form highly suggestive of endometriosis1
  • Dyspareunia
  • Commonly found in peritoneal (88) and
    rectovaginal (100) disease2
  • No relationship between stage and site of disease
  • Normal clinical examination cannot exclude
    endometriosis35
  1. Mahmood TA, Templeton A. Hum Reprod 1991
  2. Gruppo Italiano per lo Studio dellEndometriosis.
    Hum Reprod 2001.

3. Koninckx PR, Meuleman C, Oosterlynck D et al.
Fertil Steril 1996 4. Chapron C, Dubuisson JB,
Pansini V et al. Fertil Steril 2002 5. Eskenazi
B, Warner M, Bonsignore L et al. Fertil Steril
2001.
20
Endometriosis Diagnosis
  • Laparoscopy

21
Laparoscopy Advantages and disadvantages
Advantages Disadvantages2,3
Gold standard investigation technique1 Facilities/surgical expertise notuniversally available
Possibility to diagnose and treat during one procedure Not all patients are suitable forinvasive techniques
False-positive and false-negative findings
Risk of complications
  1. Kennedy S, Bergqvist A, Chapron C et al. Hum
    Reprod 2005
  2. Brosens IA, Brosens JJ. Eur J Obstet Gynecol
    Reprod Biol 2000
  3. Al-Jefout M, Dezarnaulds G, Cooper M et al. Hum
    Reprod 2009.

22
Laparoscopic Technique
23
Laparoscopic Technique
24
Laparoscopic Findings
  • Lesions1
  • Powderburn/gunshot lesions on ovaries,
    serosal surfaces, peritoneum
  • Black, dark-brown or bluish puckered lesions,
    nodules or small cystscontaining old hemorrhage
    surrounded by variable extent of fibrosis
  • Atypical or subtle lesions implants
    (petechial, vesicular, polypoid, hemorrhagic, red
    flame-like), serous/clear vesicles
  • White plaques/scarring, yellow-brown
    discoloration of peritoneum
  • Endometriomas (chocolate cysts)1
  • Contain thick tar-like fluid
  • Deeply infiltrating endometriotic nodules1
  • Extend gt5 mm beneath peritoneum
  • May involve uterosacral ligaments, vagina, bowel,
    bladder or ureters
  • Depth of infiltration related to type and
    severity of symptoms
  1. Kennedy S, Berggvist A, Chapron C et al. Hum
    Reprod. 2005.

25
Laparoscopic Disease Classification (rASRM
Score)
rASRM, revised American Society for Reproductive
Medicine.
Revised American Society for Reproductive
Medicine. Fertil Steril 1997.
26
Laparoscopic Disease Classification (rASRM Score)
MINIMAL Stage 1 (15 points) Small superficial implants, not widespread, filmy adhesions
MILD Stage 2 (615 points) Small to medium implants (13 cm), slightly deeper in peritoneum and ovary, filmy adhesions
MODERATE Stage 3 (1640 points) Large widespread implants, extensive scar tissue, filmy/dense adhesions
SEVERE Stage 4 (gt40 points) Large implants and endometriomas, extensive scar tissue, deep and dense adhesions
  • Lesion assessment based on points system at
    laparoscopy1
  • Classification may help determine risk of
    infertility
  • No correlation between classification and
    symptoms2
  1. Revised American Society for Reproductive
    Medicine. Fertil Steril 1997
  2. Kennedy S, Berggvist A, Chapron C et al. Hum
    Reprod 2005.

27
Endometriosis Diagnosis
  • Laparoscopic Images

28
Laparoscopic Images
29
Laparoscopic Images
30
Laparoscopic Images
31
Endometriosis Diagnosis
  • The Outlook

32
Diagnosis
Non-invasive techniques remain under
investigation
Detection of nerve fibres in endometrial biopsy1
Biopsy
Laboratory tests(e.g. serum cancer antigens CA
125, CA 19-9, serumIL-6, peritoneal fluid TNFa),
fail to showpredictive value4,5
Ultrasound, computerised tomography scan or
magnetic resonance imaging may be useful
adjunctive investigations2,3 Transvaginal
ultrasound can detect e.g. endometriomas (but
not lesions)1
Lab-based tests
Imaging
  1. Kennedy S, Bergqvist A, Chapron C, et al. Hum
    Reprod 2005
  2. Mounsey AL, Wilgus A, Slawson DC. Am Fam Phys
    2006
  3. Matorras R, Rodríguez F, Pijoan JI, et al. Am J
    Obstet Gynecol 1996
  1. Bazot et al. J Minim Invasive Gynecol 2005
  2. Bedawy et al. Clin Chem Acta 2004
  3. Matalliotakis et al. Arch Gynecol Obstet 2005
  4. Fraser et al. J Hum Reprod Sci 2008.

33
Endometriosis Treatment
  • Current Treatment Options

34
Overview
  • No permanent cure for endometriosis
  • Aims of treatment (patient-dependent)
  • Alleviate pain and other symptoms
  • Reduce lesions
  • Maintain/restore fertility
  • Avoid recurrence
  • Improve quality of life

35
Individualisation of Therapy
  • No single approach ideal for all patients
  • Tailor therapy to needs and choices of patient1
  • Objective of individualised therapy
  • Manage complaint (pain/infertility)
  • Optimise balance of efficacy, safety and
    tolerability profiles
  • Enhance adherence
  1. Kennedy S, Berggvist A, Chapron C et al. Hum
    Reprod 2005.

36
Surgical Therapy
  • Aimed at removing endometrial implants and
    restoring fertility
  • Efficacy reflects the skill of the surgeon
  • Recurrence is common 4050 at 5 years1,2
  1. Mounsey AL, Wilgus A, Slawson DC. Am Fam Phys
    2006
  2. Guo SW. Hum Reprod Update 2009.

37
Medical Therapy
Non-specific therapies not approved in
endometriosis Including non-steroidalanti-inflam
matory drugs and combined oral contraceptives
Specific therapies approved in
endometriosis e.g. gonadotropin-releasinghormone
agonists, danazol and some progestins
38
Treatment Approach
  • Endometriosis should be viewed as a chronic
    disease that requires a life-long management plan
    with the goal of maximising the use of medical
    treatment andavoiding repeated surgical
    procedures

Practice Committee of the American Society for
Reproductive Medicine. Fertil Steril 2008.
39
NSAIDs
  • General, non-specific pain relief
  • Controlled trial data lacking1,2
  • No single NSAID shows superior efficacy1
  • Potential adverse effects in gastrointestinal
    tract1,2

NSAID, non-steroidal anti-inflammatory drug.
  1. Allen C, Hopewell S, Prentice A. Cochrane
    Database Syst Rev 2005
  2. Kennedy S et al. Hum Reprod 2005.

40
Combined Oral Contraceptives
  • Combined oral contraceptives are widely used
    off-label for endometriosis
  • Lack of randomised controlled trials1,2
  • Limited guidance on optimal regimens
  • Estrogen in oral contraceptives appears
    counter-productive for endometriosis treatment2
  • Hormonal therapies indicated for endometriosis
    counteract estrogen effects on endometrial tissue
  • Estrogenic adverse effects (nausea, weight gain,
    water retention, increased thromboembolic risk)1
  1. Davis LJ, Kennedy SS, Moore J et al. Cochrane
    Database Syst Rev 2007
  2. Crosignani P, Olive D, Bergqvist A et al. Hum
    Reprod Update 2006.

41
Endometriosis Medical therapy
  • Specific Therapies

42
Hormonal Therapy
  • GnRH agonists
  • (suppression of FSH/LH via desensitisation and
    down-regulation of pituitary GnRH receptors)
  • Leuprolin
  • Goserelin
  • Buserelin
  • Triptorelin
  • Nafarelin
  • Avorelin
  • Progestins / antiprogestin
  • (suppression of FSH/LH, some have additional
    properties, e.g. anti-inflammatoric)
  • MPA (oral/im/sc)
  • Dydrogesterone
  • Norethisterone
  • Dienogest
  • Gestrinone
  • Androgens
  • (suppression of FSH/LH, anti-estrogenic and
    hyperandrogenism)
  • Danazol

Not all products are available in all
countries. FSH, follicle stimulating hormone
GnRH, gonadotropin-releasing hormone LH,
luteinizing hormone MPA, medroxyprogesterone
acetate
Vercellini et al. Best Pract Res Clin Obstet
Gynaecol 2008 Mihalyi et al. Expert Opin Emerg
Drugs 2006.
43
Endometriosis treatment Progestins
44
Progestins
  • Synthetic hormones with progesterone-like
    activity1,2
  • First used to treat endometriosis in the 1950s3,
    most have not been developed for the treatment of
    endometriosis
  • Derived from different steroids (e.g.
    progesterone, testosterone),differ in their
    actions
  • Limited evidence from controlled (especially
    placebo-controlled) trials, scarcity of data also
    hampers the selection of one progestin over
    another
  • Adverse events include irregular bleeding and
    (especially with older agents) weight gain,
    headaches, acne and adverse lipid changes4,5
  • Newer types selectively bind progesterone
    receptors specifically to minimise androgenic,
    estrogenic or glucocorticoid side-effects1
  1. Sitruk-Ware R. Hum Reprod Update 2006
  2. Schindler AE et al. Maturitas 2003
  3. Kistner RW. Am J Obstet Gynecol 1958
  1. Winkel CA Scialli AR. J Womens Health Gend
    Based Med 2002
  2. Vercellini P et al. Hum Reprod Update 2003.

45
Endometriosis treatment GnRH Agonists
46
GnRH Agonists
  • Synthetic peptides modelled on hypothalamic GnRH
  • Mechanism of action down-regulation of pituitary
    gonadotropin secretion, inducing a hypoestrogenic
    anovulatory state1,2
  • Considered standard treatment for endometriosis
    due to high efficacy14
  • Hypoestrogenic side-effects, including BMD
    decrease
  • Limited to short-term use (6 months) in absence
    of add-back therapy
  • Add-back therapy adds to expense optimal
    regimens not established
  • Caution in younger women not reached maximum BMD

GnRH, gonadotropin-releasing hormone BMD, bone
mineral density.
  1. Winkel CA et al. J Womens Health Gender-Based
    Med 2001
  2. Sinaii N et al. Fertil Steril 2007
  3. Crosignani P et al. Hum Reprod Update 2006
  4. Mounsey AL et al. Am Fam Phys 2006.

47
Endometriosis Surgical therapy
  • Surgery

48
Surgical Treatment
  • Usually performed as laparoscopy in one procedure
    combining diagnosis and treatment
  • Surgical intervention includes excision or
    ablation of endometriotic lesions, removal of
    endometriotic cysts, adhesiolysis1
  • Frequently combined with follow up medical
    therapy
  • Preferred approach in infertile patients2
  • Role in pain relief unclear2
  • Success reflects the skill of practitioner
  • Recurrence of endometriosis is common 5-year
    recurrence rate approximately 40503
  1. Mounsey AL, Wilgus A, Slawson DC. Am Fam Phys
    2006
  2. Jacobson TZ et al. Cochrane Database 2008
  3. Guo SW. Hum Reprod Update 2009.

49
Laparoscopic Technique
50
Endometriosis Summary
51
Summary
  • Burden
  • Physical, mental and social well-being, fertility
    and quality of life
  • Awareness
  • Lack of awareness
  • Diagnosis
  • Difficulties and delays
  • New therapies
  • Need for more effective therapies with acceptable
    tolerability
  • Progestins
  • Recommended therapy, efficacious in treating
    symptoms

52
Endometriosis
  • Questions?
About PowerShow.com