Endometriosis. Assoc.Prof.Pawin Puapornpong, Faculty of Medicine, Srinakharinwirot University.

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1 Endometriosis Assoc.Prof.Pawin Puapornpong, Faculty of Medicine, Srinakharinwirot University.

2 Endometriosis Definition: Ectopic Endometrial Tissue True Incidence Unknown:? 1-5% Does NOT Discriminate by Race Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

3 Signs and Symptoms Chronic Pelvic Pain, Dysmenorrhea Abnormal Uterine Bleeding Infertility Deep Dyspareunia Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, LBP, Hemoptysis

4 Surgical Series (Uncontrolled) 1 53% Surgical Series (Controlled) 23 47% (Infertile) 1 5% (Fertile) Population-Based Studies % Epidemiological Study 0.25 new cases/1000 woman-years Prevalence = 7.5% Endometriosis Affects ~5 Million Women, 30-40% are Infertile Prevalence Surgical Series (Uncontrolled) 1 53% Surgical Series (Controlled) 23 47% (Infertile) 1 5% (Fertile) Population-Based Studies % Epidemiological Study 0.25 new cases/1000 woman-years Prevalence = 7.5% Endometriosis Affects ~5 Million Women, 30-40% are Infertile

5 Age at Diagnosis % > 45 3% < 19 6% % %

6 Etiology: Theories Sampson: Retrograde Menstruation Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the Above No Single Theory Explains All Cases of Endometriosis

7 Diagnosis Laparoscopy ( Gold Standard) Laparotomy Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies Biopsy Preferable Over Visual Inspection

8 Appearance Endometriosis May Appear Brown Black ( Powderburn ) Clear ( Atypical ) Endometriosis May Be Associated with Peritoneal Windows

9 Treatment: Overall Approach Recognize Goals: Pain Management Preservation / Restoration of Fertility Discuss with Patient: Disease may be Chronic and Not Curable Optimal Treatment Unproven or Nonexistent

10 Classification / 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

11 Pain Management: Medical Therapy NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Misc: Opoids, TCAs, SSRIs

12 Continuous OCPs Pseudopregnancy (Kistner)? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Treatments Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects

Progestins May be as Effective as GnRH-a for Pain Control MPA 10-30 mg/day, DP 150 mg Semi-Monthly

13 Progestins May be as Effective as GnRH-a for Pain Control MPA mg/day, DP 150 mg Semi-Monthly May be Taken Long-Term Relatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea

14 Weak Androgen Danazol Suppresses LH / FSH Causes Endometrial Regression, Atrophy Expensive Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes

15 GnRH-a Initially Stimulate FSH / LH Release Down-Regulates GnRH Receptors Pseudomenopause Long-Term Success Varies Expensive Use Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1 Year )

16 Surgical Treatment (Laparoscopy / Laparotomy) Excision/ Fulgeration Resection of Endometrioma Lysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve Ablation Presacral Neurectomy Appendectomy Uterine Suspension (? Efficacy) Hysterectomy +/- BSO

17 Issues? Removal of Ovaries at Hysterectomy? Need for Progestins if ERT Given? Adjuvant Treatment Postoperatively? Lupron Challenge Test for Diagnosis? Is Endometriosis Best Treated Surgically, Medically or Both

18 Conclusion Endometriosis is a Common, Chronic Disease Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious Approach with Respect to Fertility Better Medical Therapies are Needed

19 Thank you

MANAGEMENT OF REFRACTORY ENDOMETRIOSIS

(339) MANAGEMENT OF REFRACTORY ENDOMETRIOSIS Serdar Bulun, MD JJ Sciarra Professor and Chair Department of Ob/Gyn Northwestern University ENDOMETRIOSIS OCs Teenager: severe dysmenorrhea often starting