János ARANYOS I
MD.
What is endometriosis?
• Endometriosis occurs when
tissue like that which lines
the inside of uterus grows
outside the uterus, usually
on the surfaces of organs in
the pelvic and abdominal
areas, in places that it is not
supposed to grow
The word endometriosis comes from the word “endometrium”
In what places, outside of the uterus,
do areas of endometriosis grow?
• Most endometriosis is found in
the pelvic cavity:
• On or under the ovaries
• Behind the uterus
• On the tissues that hold the
uterus in place
• On the bowels or bladder
• Myometrium, vagina, perineum
• In extremely rare cases,
endometriosis areas can grow
in the lungs, nose or other
parts of the body
Typical sites of endometriosis
When do we have to think of
endometriosis ?
• ENDOMETRIOSIS
should be
considered in
women who develop
DYSMENORRHEA
after years of painfree cycles.
Symptoms of endometriosis
One of the most common symptoms of endometriosis is
pain, mostly in the abdomen, lower back, and pelvic areas.
The amount of pain a woman feels is not linked to how
much endometriosis she has. Some women have no pain
even though their endometriosis is extensive, meaning that
the affected areas are large, or that there is scarring. Some
women, on the other hand, have severe pain even though
they have only a few small areas of endometriosis.
General symptoms of
endometriosis
• Extremely painful (or disabling) menstrual cramps;
pain may get worse over time
• Chronic pelvic pain (includes lower back pain and
pelvic pain)
• Pain during or after sex - dyspareunia
• Intestinal pain
• Painful bowel movements or painful urination during
menstrual periods
• Heavy menstrual periods
• Premenstrual spotting or bleeding between periods
• Infertility
In addition, women who are diagnosed with endometriosis may
have gastrointestinal symptoms that resemble a bowel
disorder, as well as fatigue.
Differential Diagnosis of
Endometriosis by Symptom
• Generalized pelvic pain
Pelvic inflammatory
disease
Endometritis
Pelvic adhesions
Neoplasms, benign or
malignant
Ovarian torsion
Sexual or physical abuse
Nongynecologic causes
Dysmenorrhea Primary
Secondary
(adenomyosis, myomas,
infection, cervical
stenosis)
• Dyspareunia Musculoskeletal
causes (pelvic relaxation,
levator spasm)
Gastrointestinal tract
(constipation, irritable bowel
syndrome)
Urinary tract (urethral
syndrome, interstitial cystitis)
Infection
Pelvic vascular congestion
Diminished lubrication or
vaginal expansion because of
insufficient arousal Infertility
Male factor
Tubal disease (infection)
Anovulation
Cervical factors (mucus, sperm
antibodies, stenosis)
Luteal phase deficiency
Who gets endometriosis?
• Endometriosis can affect any menstruating
woman, from the time of her first period to
menopause, regardless of whether or not
she has children, her race or ethnicity, or
her socio-economic status.
• Endometriosis can sometimes persist after
menopause; or hormones taken for
menopausal symptoms may cause the
symptoms of endometriosis to continue
Prevalence of endometriosis
• CURRENT ESTIMATES:
• 2 PERCENT
• 10 PERCENT
• of women of reproductive age
• statistics can vary widely
Endometriosis – Infertility ?
• 30 percent to 40 percent
of women with
endometriosis are infertile
• unprotected sex for 6-12
months before any
treatment for the
endometriosis
• Relation between
endometriosis and
infertility:
•Uterus does not accept embryo
•Endometriosis changes the egg
•Endometriosis gets in the way of moving a fertilized egg to the uterus
Pathogenesis of endometriosis
• Exact cause is unknown – numerous theories
• Retrograde menstrual flow
• Genes: inherit, genetic errors, „ectopic” development
(specific gene related to endometriosis has not been found yet)
• Müllerian remnants can differentiate into endometrial
tissue
• Estrogen promotes the growth of endometriosis
• Disease of the immune system
(menstrual fluid is not completely eliminated from the pelvic cavity)
• Environmental agents, chemicals, chr. infection
• Peritoneal epithelium can be "transformed" into
endometrial tissue
Diagnosis
• History, symptoms, familiar background
• Physical, bimanual, pelvic, rectal examination:
-early menses:implants are laergest and most tender
•
•
•
•
Nodules, cysts: Ultrasound, CT, MRI
Surgical: Laparoscopy, Laparotomy: direct visualisation
Biochemical: Ca-125 ? differentiate
Histological: BIOPSY during surgery
Endometriosis of the Fallopian tube
Characteristic appearance of
endometriosis
• PLAQUE
• NODULE-NODE
• CYST
• FLUID IN THE
PELVIC CAVITY
• MIXED ABDOMINAL APPEARANCE
Endometriotic plaque
Nodular endometrial lesions in the
posterior cul-de-sac
Endometriosis of the Douglas
Staging: operative procedure
•
•
•
•
LOCATION
DIAMETER
DEPTH
DENSITY of adhesions
• Stages range from minimal to severe
• Despite this standardization, the
correlation between stage and extent
of disease remains controversial.
Staging of endometriosis
Extensive endometriosis in the ovarian
fossa - petechial appearance
Treatment
•
•
•
•
Expectant
OCP, Progesteron
Medical
Surgical:
-advanced
Treatment
• Because no pharmacologic
method appears to restore
fertility, medical treatment
for endometriosis should be
reserved for use in patients
with pain or dyspareunia.
•pregnancy is contraindicated in patients receiving medical treatment
•drugs that are used interfere with ovulation
DRUG
DOSAGE
ADVERSE EFFECT
COST
Danazol (Danocrine)
800 mg per day in 2 divided doses
Estrogen deficiency,
androgenic side effects
$410,
brand
367,
generic
Oral contraceptives
1 pill per day (continuous or cyclic)
Headache, nausea,
hypertension
29
brand†
24 to
27‡,
generic
Medroxyprogesterone
suspension (DepoProvera)
100 mg IM every 2 weeks for 2 months; then 200 mg IM
every month for 4 months or 150 mg IM every 3 months
Weight gain, depression,
irregular menses or
amenorrhea
22,
brand
13,
generic
Medroxyprogesterone
(Provera)
5 to 20 mg orally per day
Same as with other oral
progestins
Norethindrone acetate
(Aygestin)
5 mg per day orally for 2 weeks; then increase by 2.5 mg
per day every 2 weeks up to 15 mg per day
Same as with other oral
progestins
113§
Leuprolide (Lupron)
3.75 mg IM every month for 6 months
Decrease in bone density,
estrogen deficiency
371,
brand
318,
generic
Gosarelin (Zoladex)
3.6 mg SC (in upper abdominal wall) every 28 days
Estrogen deficiency
470
Nafarelin (Synarel)
400 mg per day: 1 spray in 1 nostril in a.m.; 1 spray in
other nostril in p.m.; start treatment on day 2 to 4 of
menstrual cycle
Estrogen deficiency, bone
density changes, nasal
irritation
431
Treatment: OCP, Progesterone
•
•
•
•
•
•
alleviate symptoms in about 75% of patients
continuously or cyclically
discontinue after six to 12 months
suppress LH and FSH
prevent ovulation
direct effects on endometrial tissue,
rendering it thin and compact
• decidualization of endometrial implants
• lower menstrual volume
Hemorrhagic lesions
overlying the right ureter
Treatment: Danazol
• effective in relieving the symptoms of
endometriosis
• synthetic androgen that inhibits
leuteinizing hormone (LH) and folliclestimulating hormone (FSH)
• relatively hypoestrogenic state
• Endometrial atrophy
Adverse effects related to estrogen defiency include headache,
flushing, sweating and atrophic vaginitis
Androgenic side effects include acne, edema, hirsutism, deepening
of the voice and weight gain
Treatment: Danazol
• Danazol therapy should be started when the
patient is menstruating
• The initial dosage should be 800 mg per day,
given in two divided oral doses
• Dosage can be titrated down as long as
amenorrhea persists and pain symptoms are
controlled
• Treatment duration is six to nine months
• Overall response rate is 84 to 92 percent
• Beneficial effects lasting up to six months after
treatment has stopped
Treatment: GNRH
GoNadotropin Releasing Hormone 1.
• Agonists or analogues
• leuprolide [Lupron], gosarelin [Zoladex])
• inhibit the secretion of gonadotropin and
are comparable to danazol in relieving pain
• sending the body into a “menopausal” state
• hypoestrogenic side effects
• produce a mild degree of bone loss
• condition reverses after the medication is
discontinued
„add back” low dose estrogen therapy
Treatment: GNRH
GoNadotropin Releasing Hormone 2.
• Leuprolide is a single monthly 3.75-mg depot
injection given intramuscularly
• Gosarelin, in a dosage of 3.6 mg, is
administered subcutaneously every 28 days
• Nasal spray (nafarelin [Synarel]) is also
available and is used twice daily
• Response rate is similar to that with danazol;
about 90 percent of patients experience pain
relief
• Pregnancy rate after the use of these agents is
no different from that in untreated patients
Endometriosis of the ovary
Treatment: SURGERY 1.
• The usefulness of conservative surgery for pain relief
is unclear, but it appears that immediate postoperative
efficacy is at least as high as with medical treatment,
and long-term outcomes may be considerably higher
• Laparoscopy is much more expensive than medical
treatment, however, causing some physicians to argue
that overall costs can be reduced by aggressive use of
empiric treatments before surgery is considered
• Definitive surgery, which includes hysterectomy and
oophorectomy, is reserved for use in women with
intractable pain who no longer desire pregnancy
• In less severe cases, one ovary may be retained to
preserve ovarian function, although improvement will
be less definitive
Treatment: SURGERY 2.
• preferred approach to infertile patients with advanced
endometriosis
• benefit of surgery in these patients may be due entirely to
the mechanical clearance of adhesions and obstructive
lesions
• endometrial lesions are cystic or nodular and can be
excised
• hemorrhagic or petechial and amenable to laser obliteration
• recent randomized, controlled study involving 341 infertile
women with minimal or mild endometriosis demonstrated a
13 percent absolute increase in the probability of pregnancy
in a 36-week period
• Infertile patients with documented endometriosis can
benefit from the same reproductive techniques (e.g.,
superovulation, in vitro fertilization) that are used in other
infertile patients
Treatment: Laparoscopy
• The goal is to treat the endometriosis without
harming the healthy tissue around it
• Laparoscopy:
- Confirm, staging, biopsy,
- Removal of endometriosis areas
- Excision
- Electrocoagulation
- Thermocoagulation
- Laser vaporisation
Laparoscopic excision of nodular
endometrial lesions overlying the rectum.
Ovary with endometrioma
Laser may be used to obliterate
endometrial implants
Cystic implants adjacent to the right
ovary; note bluish appearance
Treatment: Infertility
Superovulation
In vitro fertilization and
embryo transfer
Treatment:
Major abdominal surgery, or laparotomy
• During laparotomy, doctors either remove the
endometriosis and/or remove the uterus
• may also remove the ovaries and fallopian tubes at the
time of a hysterectomy, if the ovaries have
endometriosis on them, or if damage is severe
• If a woman’s pain is extreme, doctors may recommend
more drastic procedures that cut the nerves in the
pelvis to lessen the pain. One such procedure can be
done during either laparoscopy or laparotomy.
Another procedure, called a laparoscopic uterine
nerve ablation (LUNA) is done during a laparoscopy.
• These procedures cannot be reversed
Huge „chocolate cyst” of the ovary
Treatment
Advantages
Disadvantages
Surgical Beneficial for infertility
Possibly better long-term
results
Definitive diagnosis
Option for definitive
treatment
Expensive
Invasive
Medical Decreased initial cost
Empiric treatment
Effective for pain relief
Adverse effects
common
Unlikely to improve
fertility
Medical management of
endometriosis
Thank You!
Sites of endometriosis
Typical sites of endometriosis