Asgari Associate Professor The presence of viable estrogensensitive endometriallike glands and stroma associated with aninflammatory response outside the uterus is globally referred to as endometriosis ID: 707444
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Slide1Slide2
ENDOMETRIOSIS
Dr. Zahra
Asgari
Associate ProfessorSlide3
The
presence of viable, estrogen-sensitive,
endometrial-like
glands and
stroma
associated with
aninflammatory
response outside the uterus is globally
referred to as endometriosis
.
Three subtypes of endometriosis
endometriomas
(
ovarian cysts)
superficial
endometriotic
implants (focus of
disease primarily on the peritoneum
)
deeply infiltrating
endometriosis (
rectovaginal
nodules).Slide4
disease affects 6–10% of
reproductive aged
Women
The average
age
is approximately 28
years
21–47% of women presenting with
subfertility
87% of those with chronic pelvic
pain
First degree relatives
of individuals
are
7
to 10-times more likely to have the disease Slide5
average time between onset of symptoms and
a definitive diagnosis is 7–8 yearsSlide6
Symptom
Percentage of
Women With
Endometriosis
Presenting
With Symptom
Confounding
Disorders
Dysmenorrhea
79
Adenomyosis
,
primarydysmenorrhea
Pelvic pain
69
Irritable bowel syndrome,
neuropathic
pain,adhesions
Dyspareunia
45
Psychosocial issues,
vaginal atrophy
Bowel symptom
36
Hemorrhoids;
constipation,inflammatory
bowel
disease
Bowel pain
29
Anal fissures
Infertility
26
Unexplained
subfertility
Ovarian mass
or tumor
20
Hydrosalpinx
, benign
ovarian cyst
Dysuria
10
CystitisSlide7
Mechanism of
Subfertility
Adhesion
Reduced AMH
Sperm damage
Altered
oocyte
cytoskeleton
Defect in endometrial biomarkers
anatomic distortion from pelvic adhesions
production of
substances
which are "hostile" to normal ovarian
function,
fertilization, and implantationSlide8
Mechanism of Pain
Cytokines
Hyperalgesic
stateSlide9
According to the Practice Committee of the American Society for Reproductive Medicine, “endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures” Slide10
Clinical manifestations of endometriosis fall into three general categories: pelvic pain, infertility, and pelvic massSlide11
There is no high quality
evidencetreatment decisions are individualized, taking into account the severity of symptoms, the extent and location of disease, whether there is a desire for pregnancy, the age of the patient, medication side effects, surgical complication rates, and costSlide12
After the initial diagnostic procedure, expectant management is considered primarily for two groups of patients: women with no or minimal symptoms and
perimenopausal women.Slide13
Initial approach
Analgesics Estrogen-progestin oral contraceptives
Thus, it is unclear whether a cyclic, continuous, or tricycle regimen is most effective [
8
]. If pain does not respond well to cyclic therapy, switching to continuous OC administration may be effective [
22
]. A monophasic pill is adequate
Treatment of pelvic painSlide14
Failure of initial medical therapy
are not achieving adequate pain relief after a three- to six-month trial with analgesics or OCs Slide15
GnRH
agonists: 6 months
Progestrons
: 6 to 12 months
bone
mineral density and lipid levels may be monitored, as appropriate, in patients on long-term therapy.
Progesterone antagonists — Progesterone antagonists and selective progesterone receptor
modulators.
Aromatase inhibitorsSlide16
Danazol
is a 19-nortestosterone derivative with progestin-like effects
.
M
echanisms :
1)
inhibition of pituitary gonadotropin
secretion
2)
direct inhibition of
endometriotic
implant
growth
3)
direct inhibition of ovarian enzymes responsible for estrogen production.
Danazol
is given orally in divided doses ranging from 400 to 800 mg daily, generally for six monthsSlide17
TREATMENT OF INFERTILITY
M
edical or Surgical?Slide18
Surgery’s aim is to remove macroscopic endometriosis implants and restore normal pelvic anatomy
.it is important to weigh up benefits versus harm of surgical
procedure
Laparoscopy is preferred to laparotomy because of advantages of minimal tissue damage, of magnification, of faster recovery, and shorter hospital stay Slide19
Several studies demonstrated that, in infertile women with endometriosis stage
I/II,
clinicians should perform operative laparoscopy (excision or ablation of endometriosis lesions) including
adhesiolysis
, rather than performing diagnostic laparoscopy only, since there is a positive effect in regards to live birth and ongoing
pregnancy
According to ESHRE guidelines,
clinicians
may consider CO
2
laser vaporization of endometriosisSlide20
In
infertile women with AFS/ASRM Stage I/II endometriosis, clinicians may perform IUI with controlled ovarian stimulation,Slide21
In infertile women with AFS/ASRM Stage III/IV endometriosis, clinicians
can consider operative laparoscopy, instead of expectant management, to increase
spontaneous
pregnancy
rates.
Consider COH/ IUI or IVFSlide22
TREATMENT OF PELVIC MASS
In women
with ovarian
endometrioma
of >3 cm in size, surgeons should perform excision of
endometrioma
capsule instead of ablative surgery that is drainage and electro-coagulation of the
endometrioma
wall. Slide23
In infertile women with
endometrioma larger than 3 cm there is no evidence that cystectomy prior to treatment with ART improves pregnancy rates
In women with
endometrioma
larger than 3 cm, the
Eshre
recommends
clinicians only to consider cystectomy prior to ART to improve endometriosis-associated pain or the accessibility of follicles. Slide24
The
Eshre
recommends that clinicians counsel women with
endometrioma
regarding the
risks of reduced ovarian function
after surgery and the possible
loss of the ovary
. The decision to proceed with surgery should be considered carefully if the woman has had previous ovarian surgery. Slide25
TREATMENT OF SYMPTOMS RELATED TO DEEP ENDOMETRIOSIS
infiltrative forms of the disease that involve the uterosacral ligaments, rectovaginal septum, bowel, ureters, or
bladder
Asymptomatic disease is managed expectantly
Medical therapy is appropriate for women with bothersome symptoms, except those with obstructive
uropathy
or symptomatic bowel
stenosis
Surgical therapy is effective for relieving pelvic pain, dyspareunia, painful defecation, and lower urinary tract
symptoms
recurrence rates of 30 and 43 percent at four and eight years
follow-up
Surgical resection does not enhance future pregnancy ratesSlide26