Investigations and management of severe endometriosis Dr Jim Tsaltas Head of Gynaecological Endoscopy and Endometriosis Surgery Monash Health Monash University Dept of O&G Melbourne IVF Freemasons Hospital
Summary Endometriosis Incidence Classification Severe Endometriosis Clinical manifestations Investigations Management
Incidence Endometriosis is the most frequent cause of chronic pelvic pain in women of reproductive age The exact prevalence of endometriosis is unknown but estimates range from 5 to 10% of women of reproductive age, to 50% of infertile women Among women with endometriosis, the reported prevalence of severe endometriosis ranges widely Estimated prevalence of endometrioisis involving rectovagina or bowel ranges from 5 to 25 percent
Classification The most widely used system by the American Society for Reproductive Medicine (ASRM) The ASRM system assigns a point score based upon the size, depth, and location of endometriosis implants and associated adhesions. The utility of the classification system is in providing a standard approach for reporting operative findings does not correlate well with patient symptoms Good correlation with prognosis for fertility, especially with advanced stage disease
Classification In general, the system classifies endometriosis as minimal, mild, moderate, or severe Stage I: minimal disease is characterized by isolated implants and no significant adhesions. Stage II: mild endometriosis consists of superficial implants less than 5 cm in aggregate, scattered on the peritoneum and ovaries. No significant adhesions are present. Stage III: moderate disease exhibits multiple implants, both superficial and invasive. Peritubal and periovarian adhesion may be evident. Stage IV: severe disease is characterized by multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions are usually present.
Severe endometriosis Divide into 2 groups: Ovarian disease (endometriomas) rectovaginal and bowel endometriosis Must remember they are not separate entities and may co exist according to the literature endometriomas are often markers of more severe disease (Banerjee 2008, Chapron 2009)
Clinical Manifestations severe endometriosis Women with rectovaginal or bowel endometriosis may present with the classic symptoms of endometriosis (dysmenorrhea, dyspareunia, and infertility) and/or with gastrointestinal symptoms Women may also be asymptomatic Chronic non-menstrual pelvic pain may also be present Dyspareunia is typically localized to the posterior vaginal wall or experienced during deep intercourse. For women with dyschezia, painful defecation may ultimately result in constipation. Rarely, women present with rectal bleeding. When bleeding is present and consistently coincides with menstrual bleeding, it is highly suggestive of rectovaginal endometriosis with infiltration into the rectal wall.
Endometriomas Endometrial tissue within the ovary. Typically contain thick brown tar-like fluid hence the name "chocolate cyst" Often densely adherent to surrounding structures the peritoneum, fallopian tubes, and bowel May be associated with symptoms of endometriosis (eg, pelvic pain, dysmenorrhea, and dyspareunia) or identified at the time of evaluation for a pelvic mass or infertility. Ruptured endometrioma may initially present with signs of acute abdomen elevated WBC, and low grade fever, similar to patients with acute pelvic inflammatory disease or appendicitis.
Endometriomas 50 percent of women with endometriosis develop endometriomas, which are often bilateral When there are ultrasound signs suggestive of endometriomas, it is likely that moderate to severe endometriosis is present
Endometriomas - Investigation Ultrasound is useful for diagnosis of endometrioma, but of limited value for diagnosis or determining extent of endometriosis at other sites since it lacks adequate resolution for visualizing adhesions and superficial peritoneal/ovarian implants. Ultrasound findings suggestive of an endometrioma include: homogeneous low to medium level echoes in a thick walled, cystic mass (unilocular or multilocular) There may be varying degrees of echogenicity in the different locules and fluid levels may be present A ground glass appearance is typical
Abnormal anatomy: Ovary Ground glass appearance Thick walled Uni- or multilocular Multiple lesions Kissing ovaries Hyperechogenic wall foci Wall nodularities Acoustic enhancement Absence of internal vascularity shifting content (No acoustic streaming) Do not regress
Endometriomas - Management Surgery is the preferred therapeutic approach for women with symptomatic or enlarging endometriomas Surgery provides Confirmation of diagnosis (diagnostic laparoscopy) Treatment of endometriomas (cystectomy) Relief from pain Exclusion of malignancy via histological diagnosis
Endometriomas - Management Laparoscopic cystectomy by excisional surgery for endometriomata 4cm or greater improves fertility(spontaneous pregnancy rates) compared to drainage and coagulation (Beretta 1998, Alborzi 2004). Many other observational studies show an increased pregnancy rate after surgery for endometriomas with a weighted mean of 50% - summarized in Vercellini 2009 As well as improved fertility rates excision has lower recurrence of endometriomas and symptoms (Hart 2008 and updated 2011 cochrane review) as compared to drainage and coagulation High quality as are RCT limitation not including expectant arm in trial may downgrade evidence to moderate quality as we do not know true rate of pregnancy with no surgery
Issues related to treatment Early studies suggested minimal if any damage to the ovarian reserve after surgical treatment for endometriomas (Loh 1999, Donnez 2001, Canis 2001) Recent studies however have demonstrated damage to the ovarian reserve Methodology to assess this includes D2 FSH, AFC, Ovarian reserve, response to gonadotrophins in IVF and AMH (Somigliani 2003, Somigliani 2006, Chang 2010, Benaglia 2010, Hirokawa 2011) Damage may also relate to size of endometrioma being excised (Roman 2010)
Reducing Risks with surgery for endometriomas Care with surgical technique Excision is preferred method Care with identification of planes Minimize diathermy and conserve all ovarian tissue possible Recent small RCT shows potential less reduction in ovarian reserve when suturing is used for haemostasis. Outcome measure was AFC (Coric 2011) Combined technique excisional surgery and also ablative surgery for 10 20% of endometrioma wall next to hilus (Donnez 2010) AMH excellent marker Should consider recommendation of routine AMH testing pre and 3 mths post endometrioma surgery Should consider egg freezing prior to recurrent endometrioma surgery in young patient with low AMH not trying to conceive
Bowel Endometriois - Distribution of disease Bowel endometriosis is most commonly found on the rectosigmoid colon Rectum (13 to 53%) Sigmoid colon (18 to 47%) Ileum or other small bowel (2 to 5%) Appendix (3 to 18%)
Surgery for Rectovaginal Lesions Early studies suggested improvement in fertility rates after management of DIE (Chapron 1999) Since that time a number of articles have been published discussing this issue Severe endometriosis which infiltrates the posterior vaginal wall and anterior rectal wall is one of the most challenging surgical issues we face as gynaecologists. There have now been a number of studies on this topic. Studies are either retrospective, observational or prospective. Surgery may be challenging and the risks of intraoperative and post operative morbidity not negligible Surgery should only be performed with the appropriate multidisciplinary set up Pregnancy rates from studies quoted vary from 23-57% (recent review Meuleman 2011) These studies vary in quality and the grade of evidence are mostly low quality with occasional moderate quality studies
Disease progression to bowel/vaginal endometriosis A nodule of the pouch of Douglas is likely the initial lesion The nodule and surrounding fibrosis may then infiltrate the rectal or vaginal walls The pouch of Douglas becomes obliterated by dense adhesions as the uterosacral ligaments develop endometriotic nodules When the nodule extends laterally, the ureter and the parametrium becomes involved
Imaging Transvaginal ultrasound Transvaginal ultrasound is the first-line imaging study when severe endometriosis is suspected A systematic review of 10 prospective studies including 1106 women reported a sensitivity of 91 percent and specificity of 98 percent for the diagnosis of rectosigmoid endometriosis. Hudelist G et al, 2011. All participants had suspected endometriosis, and all studies used surgical exploration as the reference standard Imaging field extends only to the rectosigmoid junction
Ultrasound JTsaltas Monash University
Ultrasound assessment 2 JTsaltas Monash University
Management The management of rectovaginal or bowel endometriosis depends on: The indication for treatment Pain Infertility Associated Disease anatomic location of disease Appropriate discussion and consent Multidisciplanary approach to the disease Freemasons ideal institution for this
Consent / Complications Consent is an integral part of the surgical approach to Colorectal Endometriosis Coversion to laparotomy Elective Stoma Anastomotic leak Rectovaginal fistula Alteration of bowel habit Rectal stenosis
Aim of the surgery Fertility sparing Desire of family now / Has been trying to conceive Surgery IVF Combination of Both have a plan, AMH levels may help with clinical planning Not planning a family yet Role GnRH analogues and OCP Continuously post op If family complete consider the uterus(adenomyosis) when planning colorectal surgery JTsaltas Monash University
Our Data Cooper, Reid, Tsaltas Total Group 257 patients - colorectal endo (to 30/8/2010 75 Infertility 19/75 25.3% Infertility, 56/75 74.7% pain and infertility 43 segmental resection, 28 disc excision, 4 multiple procedures 7 lost to follow up, 11 no longer wished to conceive 57 available to follow up still wishing to conceive Pregn rate 73.6 % 25.9% - spont, 68.5% ART (IVF), 5.6% mode of pregn not recorded