Endometriosis
Incidence
• 6-10% of reproductive age women
• Present in up to 75% of patients with
chronic pelvic pain
• Present in 40% of women with infertility
• FH of 1st degree relative increases risk 10
fold
• Etiology
Manifestations
• Dysmenorrhea
• Chronic pelvic pain
• Dysparunia
• Uterosacral nodularity
• Adenexal mass
• Infertility
Diagnosis
• Laparoscopy is only definite diagnostic
test
• Confirmed 80% of the time if clinically
suspected
• Appropriate to treat with only a clinical
diagnosis
Surgical Treatment
• Hysterectomy with BSO has a failure rate
of 5%
• Hysterectomy w/o BSO has a 2/3
recurrence rate and 1/3 rate of repeat
surgery
• Laparoscopic conservative surgery shows
60% improvement in pain and
40%recurrence with in 2 years
• Not clear if fertility improved by surgery
Medical Treatment
• First line is OCPs either cyclic or
continuous with or without NSAIDS
• Second line is
– Depo Provera 150mg x 3 mon
– GNRH agonists with or with out add back
– Danazol 400-600mg/d x 3-6 mon
GNRH agonists
• Leuproline (Lupron) IM 3.75-7.5mg/m or
11.25mg/3m for 3-6 month
Add Back Therapy
• Purpose is relieve hotflashes and limit
bone loss
• Start after 0-3 months of GNRH agonist
therapy
• No difference in effectiveness of treatment
for endometriosis
• Use any form of HRT (estrogen +
progestin) in lowest dose to control
hotflashes
Treatment
Flow Sheet
Clinical Diagnosis
of Endometriosis
OCPS +/- NSAIDS
Improve
Continue
Improve
Continue OGPs
Improve
Restart OCPs
No response
Laparoscopy for
diagnosis and
treatment
No responce
GnRH agonist
No responce
TAH/BSO
Miscellaneous Topics
• Value of treatment in improving fertility
in mild disease is not established
• Combination surgery followed by medical
therapy (OCP or Depoprovera) results in
best pain relief
• Ovarian endometriomas should be
managed surgically
• Mirena, continuous OCP, Depoprovera
• 48 y/o s/p TAH for fibroids
• CC: RLQ pain sudden onset 8 out of 10
• PI: Present to ER with severe pain w/o
fever, chills, nausea or vomiting, no
constipation or diarrhea
• VS: P=110, BP 135/85, afebrile
• Abdomen: diffusely tender especially in
the RLQ, with mild rebound
• Pelvic exam: Cx, uterus absent, bimanual
bulging tender firm mass felt vaginally
• CBC: Hb 12.5, WBC 11,000 normal diff
• CMP normal, UA normal
• CT: 9.5x6.7 cm multicystic right ovarian
lesion, small amount of nonspecific pelvic
fluid, appendix normal
• Returned a few hours later still in pain
• WBC 14,000 with left shift
• Sent to U of I ER/Gyn department
• U of I ER/gyn saw her, did tumor markers,
and released her
• Ultrasound in my office: 9.5x5.5 complex,
?hemorrhagic cystic mass with no blood
flow
• Consulted with U of I gyn who said tumor
markers were negative
• U of I did 23 hr stay releasing her on BCP,
po dilaudid, and follow up in 2 weeks