In the name of God
Endometriosis
symptoms of endometriosis
• pelvic pain,
• infertility,
• pelvic mass
Treatment options
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●Expectant management
●Analgesia
●Hormonal medical therapy
•Estrogen-progestin oral contraceptives, cyclic or continuous
•Gonadotropin-releasing hormone (GnRH) agonists
•Progestins, given by an oral, parenteral, or intrauterine route
•Danazol
•Aromatase inhibitors
●Surgical intervention, which may be conservative (retain uterus
and ovarian tissue) or definitive (removal of the uterus and possibly
the ovaries)
• ●Combination therapy in which medical therapy is given
before and/or after surgery
• Laparoscopy is the gold standard for
establishing the diagnosis of endometriosis,
and provides an opportunity for conservative
surgical treatment.
• Therapeutic intervention is desirable at the
time of diagnosis to ablate or excise implants
and adhesions, thus potentially preventing or
delaying
• expectant management is considered
primarily for two groups of patients:
• women with no or minimal symptoms
• perimenopausal women
TREATMENT OF PELVIC PAIN
• empiric medical therapy prior to establishing a
definitive diagnosis by laparoscopy
• medical interventions neither enhance fertility
nor diminish endometriomas or adhesions
• Therefore, women with suspected
endometriomas and advanced stages of
disease, or infertility, are more appropriately
managed surgically.
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Analgesics
Estrogen-progestin oral contraceptives
GnRH agonists
Progestins
Danazol
Aromatase inhibitors
Surgical management
• Surgery may be indicated for management of
endometriosis that cannot be treated with
medical therapy or to provide a definitive
diagnosis.
INDICATIONS
• Surgery allows both diagnosis and management for
women with known or suspected endometriosis.
Indications for surgery include:
• ●Failure of medical therapy to ameliorate symptoms
• ●Women who decline or have contraindications to medical
therapy
• ●Need for a definitive diagnosis of endometriosis –
• ●Exclude malignancy in an adnexal mass – Endometriotic
implants may develop into an ovarian cyst (endometrioma).
• ●Treatment of infertility in selected women
• ●Obstruction of the urinary tract or bowel.
• Making a definitive diagnosis requires surgery to
visualize and/or biopsy lesions.
• Women with mild symptoms suggestive of
endometriosis are often treated empirically with firstline therapies (eg, nonsteroidal anti-inflammatory
drugs [NSAIDs], estrogen-progestin contraceptives).
• If such therapy is unsuccessful, a definitive diagnosis
may be preferred prior to treating with therapies that
are difficult to tolerate and/or have potential adverse
effects (eg, gonadotropin-releasing hormone [GnRH]
agonists).
• Historically, a diagnostic laparoscopy to evaluate for
endometriosis was a standard part of the evaluation of
infertility.
• However, current practice varies.
• Some experts advise that women with infertility and
symptoms suggestive of endometriosis undergo
laparoscopy prior to other treatments, while others do not
perform laparoscopy and treat these patients in the same
stepwise manner as other women (ovulation induction with
intrauterine insemination followed by in vitro fertilization
[IVF]).
• In some cases, women are not able to undergo ovulation
induction or IVF, and laparoscopy should be performed.
CONTRAINDICATIONS
• Relative contraindications to surgical
management of endometriosis include:
• ●Incomplete evaluation of the patient’s pain –
Etiologies that do not require surgical evaluation
or treatment should be excluded prior to surgery
(primary dysmenorrhea,
interstitial cystitis/bladder pain syndrome,
irritable bowel syndrome).
• ●Repeated surgeries for endometriosis without
sustained relief.
• ●Women who are approaching menopause
SURGICAL PLANNING
• Conservative surgery: initial surgical treatment
for most wome
• Definitive surgery consists of hysterectomy
combined with bilateral salpingooophorectomy
• Conservative surgery is the first-line option for most
women planning surgical treatment of endometriosis.
• We suggest hysterectomy rather than conservative
surgery ONLY for women with persistent bothersome
symptoms of endometriosis who do not plan future
childbearing and who have both failed medical therapy
and at least one conservative treatment procedure.
• Definitive surgery is also reasonable for women who
have additional indications for hysterectomy.
• ●For women undergoing hysterectomy for
treatment of endometriosis, we suggest bilateral
salpingo-oophorectomy ONLY for those who
value decreasing the risk of reoperation more
than avoiding the risks of premature menopause.
• In general, a preference for oophorectomy is
more likely as a woman approaches menopause.
• Oophorectomy is also reasonable for women
with extensive disease involving the ovaries.
• Laparoscopy is performed for the great
majority of conservative procedures for
treatment of endometriosis, regardless of the
severity of disease.
• The laparoscopic approach allows for greater
visualization using lens magnification, faster
patient recovery, and likely less pain and
morbidity than larger abdominal incisions
PREOPERATIVE EVALUATION AND
PREPARATION
• Suspicion of deep infiltrating lesions or extrapelvic
disease
• Deeply infiltrating endometriosis (DIE) refers to lesions
that penetrate to a depth of 5 mm or more.
• These are frequently multifocal and may involve the
uterosacral ligaments, retrocervical space, bowel,
ureteral and/or bladder
• Involvement of these structures or severe pelvic
adhesive disease may require more extensive surgery.
• One study found that deep infiltrating endometriosis
occurred without disease at other sites in only 6.5
percent of patients
DIE
• If is suspected based on symptomatology (eg, dysuria, dyschezia,
hematochezia) and/or physical examination (eg, uterosacral
ligament tenderness with dense nodules, non-mobile uterus), the
preoperative evaluation should include appropriate additional
testing.
• This includes evaluation of the urinary or gastrointestinal tract.
• Extensive pelvic adhesions are difficult to diagnose with imaging.
• However, magnetic resonance imaging (MRI) or rectal sonography
may suggest an obliterated pelvic cul-de-sac
• Using transvaginal ultrasonography, one can look for the “sliding
sign” when placing the probe in the posterior fornix to see if the
anterior rectal wall glides smoothly over the retro-cervix [32].
• If there is no such sliding observed, then there
is a high probability of obliteration of the culde-sac by endometriosis. Evaluation of the
urinary and gastrointestinal tracts is discussed
• superficial endometriotic implants,
• ovarian endometriomas,
• deep pelvic nodules
• Lesions that may be confused with endometriosis
on visual examination include endosalpingiosis,
• mesothelial hyperplasia,
• hemosiderin deposition,
• hemangiomas,
• adrenal rests,
• inflammatory changes,
• splenosis, and reactions to oil-based radiographic
dyes
Classification of extent of disease
• American Society for Reproductive Medicine
(ASRM) classification system
• The classification system has a poor
correlation with pregnancy outcome or pain
• ecord the clinical score to provide a measure
of comparison of the extent of disease
between the initial and subsequent surgeries
and to plan ahead for any subsequent
operative procedure.
• Ablation – Destruction of lesions by laser
vaporization , electrosurgical fulguration, or
ultrasonic cutting and coagulation.
• ●Excision – Removal of lesions, typically with
laparoscopic scissors
• Adhesiolysis
• Surgical management of DIE requires specialized
skills to adequately remove extensive disease.
The goal is to re-establish normal anatomy. It is
vital to administer postoperative suppressive
therapy to try to prevent recurrence
• Rate of recurrence was higher for women with
more severe disease
Postoperative medical therapy
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Conservative surgical treatment generally does not obliterate the
disease burden and provide subsequent, life-long pain relief.
Symptom recurrence requiring reoperation is common and worsens
with time: 21.5 percent at two years and 40 to 50 percent after five
years
We recommend postoperative medical suppressive therapy for
most women treated surgically for endometriosis.
Several randomized trials have reported postoperative hormonal
therapy increased the duration of pain relief and delayed
recurrence of disease
Two randomized trials have found that postoperative insertion of
the levonorgestrel-releasing intrauterine device (LNG IUD) results in
decreased dysmenorrhea compared with expectant management
• The options for postoperative medical therapy
are the same as for medical therapy alone.
• Typically, first-line therapy is estrogen-progestin
contraceptives or oral progestins alone, both of
which are easy to tolerate and cost-effective.
• Another option is a LNG IUD.
• If these options are not effective, patients may
be treated with other hormonal agents (eg,
gonadotropin-releasing hormone [GnRH]
agonists), although these are associated with
more adverse effects.
• Treatment may be initiated immediately after
surgery