Endometriosis

What is Endometriosis?
n Chronic condition.
n Characterized by the growth of endometrial tissue in other sites outside the endometrial cavity.
¨ Pelvic cavity
¨ Ovaries
¨ Uterosacral ligaments
¨ Pouch of Douglas


 
What are the symptoms?
n Dysmenorrhea - recurrent painful periods
n Dyspareunia - painful intercourse
n Chronic lower abdominal and back pain
n Non-cyclic or cyclic pelvic pain
n Adnexal masses
n Subfertility

n Symptoms range from severe to minimal to no symptoms at all.


How common is endometriosis?
n Incidence is 40-60% in women with dysmenorrhea.
¨ And 20-30% in women with subfertility.

n Most common age of diagnosis is 40.


What are the causes of endometriosis?

n Retrograde menstruation
¨ Postulated in the early 1920s by Dr Sampson.
¨ Many women experience retrograde menstruation but do not go on to develop endometriosis.
¨ This theory also fails to explain why endometriosis can be found in remote areas such as the lungs, breasts, lymph nodes and even the eyes.

n The transplantation theory
¨ That endometriosis spreads via the circulatory and lymphatic system.

n Coelomic Metaplasia -
¨ This theory holds that certain cells, when stimulated, can transform themselves into a different kind of cells.
n The hereditary theory
¨ Women with family members who have endometriosis are more likely, or are susceptible to developing the disease.
n Environmental factors
¨ A great deal of research is clearly highlighting that women who are exposed to environmental toxins are at much greater risk of developing Endometriosis along with other serious health disorders.


How do you diagnose endometriosis?
n Accurate history
¨ Dysmenorrhea, pelvic pain etc.
n Physical exam
¨ Tenderness in the posterior fornix or adnexal masses
n Laparoscopy is the only diagnostic test that can reliably rule out endometriosis.
¨ Gold standard.

When do you perform laparoscopy?
n Severe pain over several months.
n Pain requiring systemic therapy.
n Pain resulting in days off from work or school.
n Pain requiring admission to the hospital.


What are the medical treatment options?
n Oral contraceptives
n Progestins
n Androgenic agents
n GnRH analogues
¨ All suppress ovarian activity and menses and cause atrophy of the endometriotic implants.
n Base decision of treatment on side effect profile.

n Endometriomas are not amenable to medical treatment.
¨ Randomized controlled trials that compare excision or drainage and ablation of endometriomas >3 cm reported recurrence rates reduced and improved spontaneous pregnancy rates.


What does surgical management entail?
n Laparoscopy or open procedures.
n Requires excision or ablation (by laser or cautery) of the implants.
n Surgical excision of endometriosis results in improved pain relief and improved quality of life after 6 months compared with diagnostic laparoscopy alone.

How often does endometriosis recur after surgery?
n Rate of recurrence is ~20% after 5 years.

What are the unanswered questions?
n Is medical or surgical management more effective?
n Does long term medical management reduce the recurrence of endometriosis?
n What is the benefit of surgery for rectovaginal disease?