Emam MA, EGYPT, 2003 Endometriosis Dr.F Mardanian MD.

Emam MA, EGYPT, 2003Emam MA, EGYPT, 2003

Endometriosis Endometriosis

Dr.F Mardanian MDDr.F Mardanian MD


DefinitionDefinition

““Presence of endometrial tissue outside Presence of endometrial tissue outside the lining of the uterine cavity” the lining of the uterine cavity”

oror ““Proliferation of endometrium in any Proliferation of endometrium in any

site other than the uterine mucosa”site other than the uterine mucosa”


Age: common in reproductive periodAge: common in reproductive period True Incidence Unknown: ? 1-5% & True Incidence Unknown: ? 1-5% &

30 – 50 % infertility.30 – 50 % infertility.

Does NOT Discriminate by Race.Does NOT Discriminate by Race.

Histology: Endometrial Glands with Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction.Stroma +/- Inflammatory Reaction.

Herdietary (Herdietary (↑↑ among sisters).↑↑ among sisters).


- Pelvic- Pelvic- Extra pelvic- Extra pelvic Umbilicus.Umbilicus. Scars (Lap.).Scars (Lap.). Lungs & plura.Lungs & plura. Others.Others.


Uterine= Adenomyosis (50%).Uterine= Adenomyosis (50%). Extraut:Extraut:

- Ovary 30%- Ovary 30%

- Pelvic peritoneum 10%.- Pelvic peritoneum 10%.

- F. tube.- F. tube.

- Vagina.- Vagina.

-Bladder & rectum.-Bladder & rectum.

- Pelvic colon.- Pelvic colon.

- Ligaments.- Ligaments.






Endometrial implantation theoryEndometrial implantation theoryRetrograde

Vascular and lymphatic

Mechanical

Immunological and genetic theoryImmunological and genetic theory Composite theoryComposite theory


Theories Of HistiogenesisTheories Of Histiogenesis

In situ development Coelomic metaplasia theory Induction theory Embryonic cell nest Wolffian ducts Mullerian ducts Germinal epithelium of ovary

continue


Predisposing FactorsPredisposing Factors

1. Hyperoestrinism:1. Hyperoestrinism:

a)a) Fibroid & metropathia hemorrhagica. Fibroid & metropathia hemorrhagica.

b)b) Delayed marriage, infertility. Delayed marriage, infertility.

c)c) Oestrogen secreting tumours of the ovary e.g. granulosa & Oestrogen secreting tumours of the ovary e.g. granulosa & theca cell tumours, or with prolonged oestrogen therapy.theca cell tumours, or with prolonged oestrogen therapy.

2. Cervical Stenosis.2. Cervical Stenosis.

3. Insufflation.3. Insufflation.

4. Curettage.4. Curettage.


Macroscopic appearanceMacroscopic appearance1) Uterine endometriosis “Adenomyosis”:1) Uterine endometriosis “Adenomyosis”:

In both types:In both types:

C/S a whorled appearance.C/S a whorled appearance.

D.D:D.D: * No capsule. * No capsule.

* Dark brown spots.* Dark brown spots.

* M/E endometrial tissue.* M/E endometrial tissue.

a) Diffuse (Common)a) Diffuse (Common) b) Localized (occasional)b) Localized (occasional)

* The uterus is * The uterus is symmetrically enlargedsymmetrically enlarged

* The uterus is * The uterus is asymmetrical enlargedasymmetrical enlarged

* Firm in consistency* Firm in consistency * Firm in consistency* Firm in consistency



Macroscopic appearance Macroscopic appearance CONT….CONT….

2) Endometriosis of the ovary:2) Endometriosis of the ovary:- The ovary is enlarged and cystic.- The ovary is enlarged and cystic.

- Surface burnt match head - Surface burnt match head appearance.appearance.

- Tunica albuginea ---> thickened.- Tunica albuginea ---> thickened. Chocolate or tarry cysts.Chocolate or tarry cysts.



Endometriosis is often misdiagnosed Endometriosis is often misdiagnosed leading to delays in treatment sometimes leading to delays in treatment sometimes for several years.for several years.

Delay in diagnosis:Delay in diagnosis:– Progression of symptoms.Progression of symptoms.

– Increasing infertility till completed Increasing infertility till completed reproductive failure.reproductive failure.


Symptoms (history).Symptoms (history).

Signs (Exam).Signs (Exam).

Investigations.Investigations.

DD.DD.

Cont…Cont…


AdenomyosisAdenomyosis Extra uterine Extra uterine endometriosisendometriosis

AgeAge About 40 About 40 yearsyears

About 30 yearsAbout 30 years

ParityParity MultiparaMultipara nulliparanullipara

SocioeconomicSocioeconomic LowLow highhigh

Cont…Cont…


SymptomsSymptoms

Asymptomatic.Asymptomatic. Pain (Pain (DYS…….): DYS…….):

- Dysmenorrhea (crescendo = progessive) - Dysmenorrhea (crescendo = progessive)

- Dyspareunia. - Dyspareunia.

- Dyschesia.- Dyschesia.

- Dysuria.- Dysuria. Backache. Backache. Acute abdomen.Acute abdomen. premenst. Tension syndrome.premenst. Tension syndrome.



Symptoms Symptoms cont…cont…

Bleeding:Bleeding:

- Menorrhagia. - Menorrhagia.

- Cyclic hematuria during menstruation.- Cyclic hematuria during menstruation.

- Cyclic bleeding per rectum during menstruation.- Cyclic bleeding per rectum during menstruation.

- Vicarious menstruation. - Vicarious menstruation. Infertility.Infertility. MassMass Intermittent pyrexia.Intermittent pyrexia.


Pelvic examination may reveal:Pelvic examination may reveal: 1. 1. Pelvic tenderness.Pelvic tenderness.

2.2. Fixed retroverted uterus. Fixed retroverted uterus.

3.3. Nodularity of the Douglas pouch and Nodularity of the Douglas pouch and uterosacral ligaments.uterosacral ligaments.

4. Ovaries4. Ovaries may may be be enlarged and tender . Ovarian enlarged and tender . Ovarian cyst maycyst may be be detected. detected.


1. Laparoscopy .1. Laparoscopy .

2. Cystoscopy and proctosigmoidoscopy.2. Cystoscopy and proctosigmoidoscopy.

3. Histopathological examination3. Histopathological examination..

4. Imaging.4. Imaging.

5. Serum CA - 125.5. Serum CA - 125.6. ? IL-8 & CEA.6. ? IL-8 & CEA.


LaparoscopyLaparoscopy

Value:Value:It permits a “see and treat” approach, It permits a “see and treat” approach,

although its effectiveness may be although its effectiveness may be limited by the nature of the disease limited by the nature of the disease and the surgeon's skill.and the surgeon's skill.


Appearance:Appearance:Endometriosis May AppearEndometriosis May AppearBrownBrownBlack (“Powderburn”)Black (“Powderburn”)Clear (“Atypical”)Clear (“Atypical”)

Endometriosis May Be Associated Endometriosis May Be Associated with Peritoneal Windowswith Peritoneal Windows

Laparoscopy Laparoscopy cont….







1. Ovarian cysts.1. Ovarian cysts.2. Pelvic inflammatory disease .2. Pelvic inflammatory disease .3. Other causes of nodularity in Douglas 3. Other causes of nodularity in Douglas

pouch as tuberculous peritoni tis and pouch as tuberculous peritoni tis and metastases of ovarian cancer.metastases of ovarian cancer.

4. Causes of 4. Causes of haematuriahaematuria , , bleeding per rectumbleeding per rectum and and acute abdominal painacute abdominal pain if the patient is if the patient is presented by one of these symptoms.presented by one of these symptoms.

5. Asymmetrical enlarged uterus.5. Asymmetrical enlarged uterus.



Ovarian Endometriosis Ovarian Endometriosis (Endometrioma)(Endometrioma)

Formed by invagination of the Formed by invagination of the ovarian cortex after accumulation ovarian cortex after accumulation of menstrual debris from bleeding of menstrual debris from bleeding of endometriotic implants.of endometriotic implants.


Rectovaginal Septum Rectovaginal Septum EndometriosisEndometriosis

Nodules are formed by Nodules are formed by hyperplasia of smooth muscles hyperplasia of smooth muscles and fibrous tissue surrounding and fibrous tissue surrounding the infiltrated tissue.the infiltrated tissue.

No cyclical bleeding as the No cyclical bleeding as the endometriotic tissue are enclosed endometriotic tissue are enclosed in nodules.in nodules.


Classification / StagingClassification / Staging

Several Proposed Schemes.

Revised AFS System: Most Often Used.

Ranges from Stage I (Minimal) to Stage IV (Severe).

Staging Involves Location and Depth of Disease, Extent of Adhesions.



Revised AFS 1985Revised AFS 1985

Stage I (minimal) 1 – 5. Stage II (mild) 6 – 15. Stage III (moderate) 16 – 40. Stage IV (severe) > 40.


Treatment : ConsiderationTreatment : Consideration

Age.Age.

Symptoms.Symptoms.

Stage.Stage.

Infertility.Infertility.


Treatment (Rationale)Treatment (Rationale)

Recognize Goals: Recognize Goals: –– Pain ManagementPain Management

–– Preservation / Restoration of FertilityPreservation / Restoration of Fertility Discuss with Patient:Discuss with Patient:

–– Disease may be Chronic and Not CurableDisease may be Chronic and Not Curable

–– Optimal Treatment Unproven or Optimal Treatment Unproven or Nonexistent Nonexistent


Endometriosis & IVFEndometriosis & IVF

The presence of endometriosis does not The presence of endometriosis does not generally impair the results of IVF but it generally impair the results of IVF but it increases the risk of infection.increases the risk of infection.

It is preferable not to cauterize ovarian It is preferable not to cauterize ovarian endometrioma if IVF or ICSI is indicated endometrioma if IVF or ICSI is indicated for fear of destruction of ovarian tissues.for fear of destruction of ovarian tissues.


Expectant.Expectant.

Medical.Medical.

Hormonal.Hormonal.

Surgical.Surgical.


(I)(I) Expectant treatmentExpectant treatment

Young , asymptomatic infertile Young , asymptomatic infertile patient with mild endometriosis.patient with mild endometriosis.

If pregnancy does not achieved If pregnancy does not achieved within 12 - 18 months of observation:within 12 - 18 months of observation:

- hormonal or surgical treatment is - hormonal or surgical treatment is indicated .indicated .


(II) Medical Treatment(II) Medical Treatment

Symptomatizing patients with Symptomatizing patients with minimal or mild lesions:minimal or mild lesions:

1. Analgesics : for pain.1. Analgesics : for pain.

2. Prostaglandin inhibitors.2. Prostaglandin inhibitors.

3. Pregnancy.3. Pregnancy.

4. Opoids.4. Opoids.

5. NSAID.5. NSAID.


(Ill) Hormonal treatment(Ill) Hormonal treatment

Oestrogen.Oestrogen. Combined oestrogen-progestogen Combined oestrogen-progestogen

Pills.Pills. Progestins.Progestins. Danazol.Danazol. GnRH agonists.GnRH agonists.


Indications of Hormonal tttIndications of Hormonal ttt

1. Small endometriotic; lesions.1. Small endometriotic; lesions.2. Recurrence after conservative surgery.2. Recurrence after conservative surgery.3. Preoperative for 6-12 weeks to decrease 3. Preoperative for 6-12 weeks to decrease

size.size.4. Postoperative for residual lesions.4. Postoperative for residual lesions.5. When operation is contraindicated or 5. When operation is contraindicated or

refused by the patient.refused by the patient.


Aim of the hormonal therapyAim of the hormonal therapy(A) Pseudopregnancy :(A) Pseudopregnancy :1. 1. Combined low - dose contraceptive pills(6 - 18 Combined low - dose contraceptive pills(6 - 18

months to inhibit ovulation and menstruation and months to inhibit ovulation and menstruation and induce decidualization to endometriotic tissues).induce decidualization to endometriotic tissues).

oror2. 2. Progestins (to avoid oestrogen's side effects Progestins (to avoid oestrogen's side effects

medroxy progesterone acetate Depo medroxy medroxy progesterone acetate Depo medroxy progesterone acetate (DMPA) can be given in a progesterone acetate (DMPA) can be given in a dose of 150 mg IM every I - 3 months .dose of 150 mg IM every I - 3 months .


Aim of the hormonal therapy Aim of the hormonal therapy cont….cont….

(B) Pseudomenopause (induction (B) Pseudomenopause (induction of amenorrhoea) by:of amenorrhoea) by:

1. Danazol.1. Danazol.

2. Gn RH analogues.2. Gn RH analogues.

3. Gestrinone.3. Gestrinone.

4. Gossypol.4. Gossypol.


DanazolDanazol Weak Androgen (isoxazole derivative of 16 – Weak Androgen (isoxazole derivative of 16 –

alpha ethinyl testosterone).alpha ethinyl testosterone). Suppresses LH / FSH.Suppresses LH / FSH. Causes Endometrial Regression, Atrophy.Causes Endometrial Regression, Atrophy. Expensive.Expensive. Dose 400 – 800 mgm orally /day/ 6 – 9 months.Dose 400 – 800 mgm orally /day/ 6 – 9 months. Side-Effects: Weight Gain, Masculinization, Side-Effects: Weight Gain, Masculinization,

Occ. Permanent Vocal ChangesOcc. Permanent Vocal Changes


GnRH-aGnRH-a Initially Stimulate FSH / LH Release.Initially Stimulate FSH / LH Release. Down-Regulates GnRH Down-Regulates GnRH

Receptors–”Pseudomenopause”.Receptors–”Pseudomenopause”. Long-Term Success Varies.Long-Term Success Varies. Expensive.Expensive. Use Limited by Hypoestrogenic Effects.Use Limited by Hypoestrogenic Effects. May be Combined with Add-Back (? >1 May be Combined with Add-Back (? >1

Year ), using E2/progesterone preparation.Year ), using E2/progesterone preparation.


GnRH-aGnRH-aAddback Addback ((E2/progesterone E2/progesterone

preparation)preparation) : :Reduce effect on bone Reduce effect on bone

mineral density.mineral density.Relieve hot flushes.Relieve hot flushes.


GossypolGossypol Is a phenolic compound extracted from the seed , stem Is a phenolic compound extracted from the seed , stem

and root of the cotton plant. and root of the cotton plant. It is a sup pressor of FSH and LH , producing It is a sup pressor of FSH and LH , producing

endomelrial atrophy in about 50% of patients after 3 endomelrial atrophy in about 50% of patients after 3 months .months .

Dose : 20 mg daily for 2 months then 25 mg twice Dose : 20 mg daily for 2 months then 25 mg twice weekly for main tenance .weekly for main tenance .

Side effects : include electrolyte disturbance especially Side effects : include electrolyte disturbance especially hypokalaemia and alteration of hepatic and renal hypokalaemia and alteration of hepatic and renal functions .functions .


GestrinoneGestrinone It is a synthetic 19 Nor steroid exhibits marked and It is a synthetic 19 Nor steroid exhibits marked and

- progcs-terogenic and anti - oestrogenic as well as - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties mild androgenic and anti -gonadotrophic properties ..

The endocrine effects of Gestrinone are similar to The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of those of Danazol which leads mainly to inhibition of ovari an steroidogenesis . ovari an steroidogenesis .

The dose is 2.5 - 5 mg orally twice weekly .The dose is 2.5 - 5 mg orally twice weekly .


Surgical Treatment Surgical Treatment (Laparoscopy / Laparotomy)(Laparoscopy / Laparotomy)

Excision Excision sí sí / Fulgeration / Fulgeration no!no! Resection of Endometrioma.Resection of Endometrioma. Lysis of Adhesions, Cul-de-sac Reconstruction.Lysis of Adhesions, Cul-de-sac Reconstruction. Uterosacral Nerve Ablation.Uterosacral Nerve Ablation. Presacral Neurectomy.Presacral Neurectomy. Appendectomy.Appendectomy. Uterine Suspension (? Efficacy).Uterine Suspension (? Efficacy). Hysterectomy +/- BSO.Hysterectomy +/- BSO.



IssuesIssues

? Removal of Ovaries at Hysterectomy ? Removal of Ovaries at Hysterectomy ? Need for Progestins if ERT Given? Need for Progestins if ERT Given ? Adjuvant Treatment Postoperatively? Adjuvant Treatment Postoperatively ? Lupron Challenge Test for Diagnosis? Lupron Challenge Test for Diagnosis ? Is Endometriosis Best Treated ? Is Endometriosis Best Treated

Surgically, Medically or BothSurgically, Medically or Both


Conservative surgeryConservative surgery

1. Large adnexal masses .1. Large adnexal masses .2. Failure of medical and 2. Failure of medical and

hormonal treatment.hormonal treatment.3. Severe endometriosis 3. Severe endometriosis

(follow principles of (follow principles of microsurgery).microsurgery).


The Principles of The Principles of Microsurgical TechniqueMicrosurgical Technique

1. The use of magnification by microscope or 1. The use of magnification by microscope or head loupes.head loupes.

2. gentle handling of tissues.2. gentle handling of tissues.

3. meticulous tissues dissection.3. meticulous tissues dissection.

4. precise haemostasis.4. precise haemostasis.

5. careful approximation of tissues.5. careful approximation of tissues.


The Principles of Microsurgical The Principles of Microsurgical Technique Technique cont…cont…

6. Irrigation of the field with heparined Ringer's lactate.6. Irrigation of the field with heparined Ringer's lactate.

7. The use of non - or delayed absorbable suture 7. The use of non - or delayed absorbable suture material , cut gut should be avoided as it is irritant to material , cut gut should be avoided as it is irritant to the tissue.the tissue.

8. Contamination of the pelvis with foreign material as 8. Contamination of the pelvis with foreign material as talc powder from gloves should be avoided as it talc powder from gloves should be avoided as it provokes inflammation .provokes inflammation .

9. Intra - operative dextran 70.9. Intra - operative dextran 70.

10. postoperative corlicosteroids and prophylactic 10. postoperative corlicosteroids and prophylactic antibiotics may be used .antibiotics may be used .


ConclusionConclusion Endometriosis is a mystery tour as it Endometriosis is a mystery tour as it

requires decision making at every requires decision making at every stage by the physician and the stage by the physician and the patient.patient.

Endometriosis still stand as one of Endometriosis still stand as one of the most-investigated disorders in the most-investigated disorders in gynecology. gynecology. SOSO is one of the highest is one of the highest priorities for research.priorities for research.


OB& GYN, Mansoura Faculty of Medcine

Mansoura Integrated Fertility Center (MIFC) EGYPT

Telfax 0020502319922 & 0020502312299

Email. [email protected]

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Emam MA, EGYPT, 2003 Endometriosis Dr.F Mardanian MD.

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