ENDOMETRIOSIS
Dr. Nayan Sarkar MD(JIPMER), DNB
Assistant Professor,
Department of Obst. And Gynae
Learning objectives----Define endometriosis
Evaluate a case of endometriosis
Understand the importance of
diagnosis, management of such a case
How to manage a case of endometriosis
Definition
Presence of endometrium-like glands
and stroma outside the uterus
Adenomyosis = Invasion of the
myometrium by endometrial tissue
Prevalence
Not precisely known—2-5%
20-40% of women in infertile couple vs. 5%
of fertile women.
But also found in 6-43% of women
undergoing laparoscopic sterilization.
52% of teenagers with CPP Syndrome.
Up to 80% women with CPP
What you might see..
Endometriomas
May reach up to 15-20cm
“Chocolate cysts”
Pathogenesis
Direct implantation of endometrial cells
– by means of retrograde menstruation
Vascular and lymphatic dissemination of
endometrial cells
Coelomic metaplasia of multipotential
cells in the peritoneal cavity
Composite
Immune factors
Retrograde menstruation happens in
nearly everyone – so why do some
women get endometriosis??
Macrophages are found in higher
concentration in the peritoneal fluid of
women with endometriosis
They secrete growth factors and
cytokines
Familial association
Relative Risk to siblings 2.3 overall
Relative Risk to sibs if severe
endometriosis 15
Risk factors
Single/ nulliparous
Early menarche
Non oral contraception
Non smoker
shorter cycle/longer duration of flow
Dysplastic naevus syndrome, melanoma
symptoms
Severe dysmenorrohoea (90%)
Chronic Pelvic Pain (70%)
Deep dyspareunia (75%)
infertility (55%)
Presentation
Pelvic pain - Most common**
Dysmenorrhea
Deep thrust dyspareunia
Infertility – May be only complaint
Abnormal bleeding
Cyclical hematochezia or hematuria
Endometriosis pain
Psycho-physical treatmentsaccupuncture, massage, relaxation,
Exercise
Anti-oestrogen drugs.
Laparoscopy/open surgery
Infertility
May be caused by distortion of the pelvic
anatomy
Severe adhesions may impair egg release,
block sperm entry into fallopian tube, or
inhibit ovum pickup
May be other mechanisms as well –
anovulation, immune dysfunction, corpus
luteum insufficiency, embryo or sperm
toxicity of peritoneal fluid…
Infertility mechanisms
Adhesions
distorsion
Increased
PGs
Defective
folliculoge
nisis
LUFFS
Altered
Cytokines
tubal motil
Fertilizatio hyperprola
n failure
ctinaemia
Chronic
salpingitis
Impaired
oocyte
pick up
Cell
mediated
gamete inj
Activated Increased
macrophag prev. ABs
Sperm
Early spon Luteal
phagocyto abortion
phase
sed
deficency
Where can’t it go?
Most common – Ovaries (60%), pelvic
peritoneum, ant and post cul-de-sacs,
uterosacral ligaments, tubes, pelvic lymph
nodes
Infrequent – Recto sigmoid (10-15%), other GI
sites (5%), vagina
Rare – Umbilicus, episiotomy or surgical scars,
kidney, lungs, arms, legs, nasal mucosa,
brain
Differential Diagnosis
Pain - Chronic PID, Adhesions, GI dysfunction,
Interstitial cystitis
Dyspareunia – Chronic PID, Ovarian cysts,
Symptomatic uterine retroversion
AUB – Anovulation, Hypothyroidism,
Hyperprolactinemia
Premenstrual spotting – Luteal phase defect,
Polyps, Cervical lesions
Acute pain – Ecoptic, PID, Torsion, Ruptured
corpus luteum
Evaluation
H&P
Transvaginal U/S
MRI – Helpful in detecting rectal involvement
Colonoscopy and barium enema if GI
bleeding present
Diagnostic laparoscopy
Conscious pain mapping
hpe
Definitive diagnosis can only be made
with tissue bx
Will see endometrial
glands, stroma, and
hemosiderin-laden
macrophages
American Society of Reproductive
Medicine
Classification
Stage 1 (min)
– 1-5
Stage II (mild)
– 6-15
Stage III (mod)
– 16-40
Stage IV (severe)
– >40
treatment
Is treatment always required?
Who needs treatment?
Does any treatment really work?
Does treatment in young women
prevent infertility and progression?
Difficult to answer
Endometriosis progress in most cases of
moderate and severe disease.
Spontaneous regression can occur in up
to 58% of milder cases.
Natural history is still uncharted to a
large extent.
However---Medical treatment and surgery fail to arrest
disease in up to a third.
Combinations of treatments have also failed
to control disease for indefinite periods when
followed up.
Pregnancy has a variable effect on
endometriosis—persistence, regression and
progression.
And also------Endometriosis may occur in the early
menopause, usually in association with HRT.
Laparoscopic ablation of visible endometriotic
lesion in infertile women is associated with
significantly increased fertility rates.
There is no data regarding early intervention
wrt prevention.
Treatment
Expectant
Medical – Good for patient’s with
symptoms who desire pregnancy in the
future
Surgery – Conservative or extirpative
**There is no cure**
Medications
Analgesics (NSAIDs)
OCPs
Progestins – Provera, Depo Provera
Danazol (17 alpha-ethinyl testosterone
derivative)
GnRH agonists (Lupron)
Treatment of pain
NSAIDS: all significantly better than
placebo, studies vary which one is best
Naproxen >mefanemic acid>aspirin
Naproxen=ibuprofen
Naproxen only drug with significant SEs
treatment of menstrual pain
Treatment
level of evidence
Simple analgesics
Herbal remedies
alcohol
Antidepressants/ anxiolytics
OCPs
NSAIDS
1
1
2
2
1
3
OCPs
OCPs cause a decidual reaction in the
functioning endometriotic tissue
Usually use low-dose OCPs continuously
for 6-9 months
Contraindications – Smoker >35, hx of
thromboembolic disease
Progestins
Can use oral or depot
medroxyprogesterone acetate
Progestins suppress gonadotropin
release and in turn ovarian
steroidogenesis
There may be a prolonged interval to
resumption of ovulation with Depo so it
should not be used in women who
desire fertility in the near future
Danazol
Derivative of synthetic steroid 17α-ethinyl
testosterone – has progestagenic and
androgenic effects
Suppresses LH and FSH mid cycle surges so
the ovary no longer produces estrogen
Symptomatic relief in 80% of pts with
recurrence in 5-20% after discontinuing
therapy
Side effects – weight gain, acne, hirsutism,
oily skin, decrease in breast size
GnRH agonist
Desensitizes the pituitary and impairs release
of LH and FSH and therefore estrogen
production
Less androgenic side effects than Danazol
Aromatase inhibitors
Aromatase catalyzes the conversion of
testosterone to estradiol
Being evaluated for use in refractory
cases of endometriosis
Letrozole for 6 months has showed
promising results in studies
Limitations of drug therapy
Only shrinks some types of endometriosis
which are oestrogen sensitive i.e. red and
blister appearance not brown, black and
white.
Shrinkage not complete– usually leaves micro
disease.
Results for infertility treatment no better than
no treatment.
Does not deal with adhesions.
Conservative surgery
Typically in patients who would like to
retain their fertility
Goal is to destroy all visible implants
and adhesions
87% of patients report improvement in
pain following ablation
High recurrence rates
Extirpative surgery
TAH, BSO, and removal of implants
If all ovarian tissue is removed, it is
unlikely residual disease will be
stimulated
May leave ovarian tissue in younger
patients but they may require further
surgery
Pregnancy rates after
laparoscopy
Without
surgery
After
surgery
Minimal/Mil
d
37.4%
Moderate/
Severe
3.1%
51.7%
41.3%
META-ANALYSIS MIN/MILD
ENDOMETRIOSIS
PREG
RATE
NO TREAT
44%
DRUG
THERAPY
SURGERY
IVF
n
235
FOLLOWUP
0.5-3
41%
418
1- 5
65%
912
1-6
20
257
Assesment
Best method to diagnose
endometriosis
MRI
USG
Laparoscopy
PAP Smear
Advanced endomeriosis may
contribute to sub fertility by
Distorting tubal anatomy
Causing apareunia
Creating a hostile peritoneal
environment
Affecting sperm transport
Facts about endometriosis
Disease severity is and indicator of the
amount of pain experienced by the
patient
F
65% of the patients have ovarian
involvement
Commonly presented with superficial
dyspareunia
Is easily diagnosed by clinical
examination in an outpatient setting
Concerning endometrioma
Less than 3 cm cyst may be managed
effectively medically
Cyst aspiration by usg guidance is
associated with high recurrence rate
Ovulation induction with follitropin
requires higher doses to yield similar
result
Excision of the cyst with thermal injury
to its base is the treatment of choice
Consisting ART in woman with
advanced stage endometriosis
Ovulation induction alone is a valid
option
IVF-ET is a recognized first line of
treatment
Success rates are similar to those
women with tubal disease
Medical therapy prior to ART increases
success
Concerning conservative surgery for
advanced stage disease in woman with
subfertility
Pregnancy rate following laparotomy
are significantly higher than following
laparoscopy
Excision of endometriotic deposits in
the POD improves fecundity
Recurrence is uncommon
It has little effect on quality of life
measures
Concerning medical treatment for
advanced stage of endometriosis and
infertility
GNRH agonists are the treatment of
choice for the suppression of symptoms
Pregnancy rates following
discontinuation of medical therapy are
similar to those following surgery
Ovarian suppression following surgery
improves subsequent pregnancy rates