ENDOMETRIOSIS
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FIRST – A FEW QUESTIONS!
IS TREATMENT ALWAYS REQUIRED?WHO NEEDS TREATMENT?DOES ANY TREATMENT REALLY WORK?DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?
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I DON’T HAVE THE ANSWERS
ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASESPON REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT
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HOWEVER----
MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRDCOMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UPPREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSIS—PERSISTENCE, REGRESSION AND PROGRESSION
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AND ALSO---------
ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRTLAPAROSCOPIC ABLATION OF VISIBLE ENDO IN INFERTILE WOMEN IS ASSOC WITH SIGNIFICANTLY INCREASED FERTILITY RATESTHERE IS NO DATA REGARDING EARLY INTERVENTION WRT PREVENTION
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PREVALENCE
NOT PRECISELY KNOWN—2-5%20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMENBUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION52% OF TEENAGES WITH CPP SYNDROME
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Familial association
Relative Risk to siblings 2.3 overall
Relative Risk to sibs if severe endo 15
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Risk factors
Single/nulliparousEarly menarcheNon oral contraceptionNon smoker shorter cycle/longer duration of flowDysplastic naevus syndrome, melanoma
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symptoms
90% severe dysmenorrohoea70% chronic pelvic pain75% dyspareunia55% infertility
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Infertility mechanisms
Adhesions distorsion
Increased PGs
Cell mediated gamete inj
Defective folliculogenisis
Chronic salpingitis
Activated macrophag
Increased prev. ABs
LUFFS
Altered tubal motil
Cytokines Fertilization failure
hyperprolactinaemia
Impaired oocyte pick up
Sperm phagocytosed
Early spon abortion
Luteal phase deficency
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Treatment of pain
NSAIDS: all significantly better than placebo, studies vary which one is bestNaproxen >mefanemic acid>aspirinNaproxen=ibuprofenNaproxen only drug with significant SEs
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treatment of menstrual painTreatment level of
evidenceSimple analgesics 1Herbal remedies 1 alcohol 2Antidepressants/anxiolytics 2OCPs 1NSAIDS 3
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ENDOMETRIOSIS PAIN
PSYCO-PHYSICAL TREATMENTS-ACCUPUNCTURE, MESSAGE, RELAXATION, TENSEXERCISEANTI-OESTROGEN DRUGSLAPAROSCOPY/ OPEN SURGERY
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LIMITATIONS OF DRUG THERAPY
ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITESHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASERESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENTDOES NOT DEAL WITH ADHESIONS
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META-ANALYSIS MIN/MILD ENDOMETRIOSIS
PREG RATE
n FOLLOW-UP
NO TREAT
44% 235 0.5-3
DRUG THERAPY
41% 418 1- 5
SURGERY 65% 912 1 - 6
IVF 20 257
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