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ENDOMETRIOSIS Dr. Zahra ENDOMETRIOSIS Dr. Zahra

ENDOMETRIOSIS Dr. Zahra - PowerPoint Presentation

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ENDOMETRIOSIS Dr. Zahra - PPT Presentation

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

women endometriosis ovarian pain endometriosis women pain ovarian pelvic disease bowel symptoms endometrioma treatment surgical clinicians therapy rates pregnancy surgery laparoscopy infertile

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Slide1
Slide2

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