1. Management
of
Endometriosis
ESHRE GUIDELINES 2013
Best Clinical Practice Guidelines
Ever Produced on
Dr. Jyoti Bhaskar
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Namitha kapoor

2. Which symptoms areWhich symptoms are
associated with or predictive ofassociated with or predictive of
the diagnosis ofthe diagnosis of
endometriosis?endometriosis?
?
BIGQUESTION1

3. Delay to Diagnosis
8 to 10 years
Delay of
• 10 years in Germany and Austria
• 8 years in the UK and Spain,
• 7 years in Norway, Italy
• 4–5 years in Ireland and Belgium
INDIA--- ?

4. In the presence of gynaecological symptoms
such as:
• dysmenorrhoea – 40%
• non-cyclical pelvic pain– upto 80%
• deep dyspareunia – 44%
• infertility -- 40%
• fatigue in the presence
of any of the above.
Clinicians should consider the diagnosis of
Endometriosis:

5. In women of reproductive age with
non-gynaecological cyclical symptoms:
• dyschezia
• dysuria
• haematuria
• rectal bleeding
• shoulder pain.

6. What findings during
clinical examination are
predictive for the
Presence and localization
of pelvic endometriosis?
BIGQUESTION2
?

7. Clinicians should perform Clinical Examination
in all women suspected of endometriosis
• It should include both-
• Per Abdomen
• Per Speculum
• Per Vaginum
• Highest predictive value
• -- Menstruation

8. For adolescents and/or women without
previous sexual intercourse
• Rectal examination can be helpful for
the diagnosis of endometriosis.
• Only after Counselling and Verbal
Consent

9. Suspect Deep Endometriosis
• Women with (painful) induration and/or
nodules of the Rectovaginal wall found
during clinical examination or
• Visible vaginal nodules in the posterior
vaginal fornix

10. Consider Ovarian Endometriosis
Adnexal Masses
detected during clinical examination

11. Be Obsessed with Endometriosis
• In women suspected of the disease
even if the clinical examination is
NORMAL

12. Can the diagnosis ofCan the diagnosis of
endometriosis be made byendometriosis be made by
application of specificapplication of specific
medical technologies?medical technologies?
?
BIGQUESTIONNO.3BIGQUESTIONNO.3

13. The Diagnosis of Endometriosis
Based on the
• History
• Symptoms and signs,
• Corroborated by physical examination &
imaging techniques
• And finally proven by histological
examination of specimens collected during
laparoscopy

14. Laproscopy & Histology
– Gold Standard
• Perform a laparoscopy to diagnose endometriosis
• Confirm a positive laparoscopy by histology, since
positive histology confirms the diagnosis of
endometriosis even though negative histology does not
exclude it.
• Clinicians should obtain tissue for histology to exclude
rare instances of malignancy.

15. Ovarian Endometrioma
Perform TVS
diagnose or to exclude an ovarian Endometrioma

16. Ultrasound features
• Ultrasound
characteristics in
premenopausal women
1. Ground Glass
echogenicity
2. one to four
compartments
3. no papillary structures
with detectable blood
flow

17. Ultrasound for Rectal Endometriosis
• TVS is highly operator dependent, and
experience is often lacking
• TVS is not recommended for diagnosis of
rectal endometriosis
• 3D ultrasound to diagnose rectovaginal
endometriosis is not well established

18. • Clinicians should assess ureter, bladder and
bowel involvement by additional imaging if
there is a suspicion based on
history or physical examination of deep
endometriosis.
• Barium enema, Transvaginal sonography
(TVS), Transrectal sonography and MRI
DEEP ENDOMETRIOSIS

19. Magnetic Resonance Imaging
????
• Clinicians should be aware that the usefulness
of magnetic resonance imaging (MRI)
to diagnose Peritoneal Endometriosis
is not well established

20. Biomarkers ????
Clinicians are recommended not to use
biomarkers to diagnose endometriosis in
• endometrial tissue,
• menstrual or uterine fluids
• and/or immunological biomarkers, including
CA-125, in plasma, urine or serum

21. Treatment of
Endometriosis-associated
Pain

22. Empirical treatment of pain ?Empirical treatment of pain ?
?
BIGQUESTIONNO.4BIGQUESTIONNO.4

23. Clinicians should
• Counsel women with symptoms presumed
to be due to endometriosis thoroughly
• Empirically treat them with
1. adequate analgesia,
2. combined hormonal contraceptives or
progestagens.

24. Are hormonal therapiesAre hormonal therapies
effective for painful symptomseffective for painful symptoms
associatedassociated
with endometriosis?with endometriosis?
?
BIGQUESTIONNO.5BIGQUESTIONNO.5

25. Clinicians are recommended
• Prescribe hormonal treatment as one of the options
1. Hormonal contraceptives
2. Progestagens
3. Anti-progestagens
4. GnRH agonists
• To take patient preferences, side effects, efficacy,
costs and availability into consideration when
choosing hormonal treatment

26. Progestagens and anti-progestagens.
PROGESTAGENS [medroxyprogesterone acetate
(oral or depot), dienogest, cyproterone acetate,
norethisterone acetate or danazol] or
ANTI-PROGESTAGENS (gestrinone) as one of the
options, to reduce endometriosis-associated pain
• To take the different side-effect profiles of
progestagens and anti-progestagens into account

27. LNG-IUS
• To consider levonorgestrel-releasing
intrauterine system (LNG-IUS) as one of the
options to reduce endometriosis-associated
pain

28. GnRH Agonist
• Use GnRH agonists (nafarelin,leuprolide,
buserelin, goserelin or triptorelin), although evidence
is limited regarding dosage or duration of treatment
• Prescribe hormonal add-back therapy to
coincide with the START of GnRH agonist therapy
• To give careful consideration in young women
and adolescents

29. Aromatase inhibitors
• In women with pain from rectovaginal
endometriosis, refractory to other
medical or surgical treatment,
Consider prescribing aromatase
inhibitors in combination with oral
contraceptive pills, progestagens or GnRH
analogues

30. Are analgesics effective forAre analgesics effective for
symptomatic relief of painsymptomatic relief of pain
associated withassociated with
endometriosis?endometriosis?
BIGQUESTIONNO.6BIGQUESTIONNO.6

31. The GDG recommends that
clinicians should consider NSAIDs
or other analgesics to reduce
endometriosis-associated pain.
NSAIDS

32. Is surgery effective for painfulIs surgery effective for painful
symptoms associated withsymptoms associated with
endometriosis?endometriosis?
?
BIGQUESTIONNO.7BIGQUESTIONNO.7

33. Laparotomy and laparoscopy are equally
effective
Laparoscopic surgery is usually associated
• with less pain,
• shorter hospital stay
• quicker recovery
• better cosmetic outcome,
Laparoscopy is usually preferred

34. • When endometriosis is identified at
LAPAROSCOPY, clinicians are recommended to
surgically treat endometriosis,
as this is effective for reducing endometriosis-
associated pain, i.e.
‘SEE AND TREAT’

35. • Clinicians may consider both ablation and
excision of peritoneal endometriosis
• Excision of lesions could be preferential
PERITONEAL ENDOMETRIOSIS

36. Ovarian Endometrioma
CYSTECTOMY
• PERFORM CYSTECTOMY instead of drainage
and coagulation, as cystectomy reduces
endometriosis-associated pain
• CYSTECTOMY NOT CO2 laser vaporization
because of a lower recurrence rate of the
endometrioma

37. Deep Endometriosis
• Clinicians can consider performing
Surgical removal of deep endometriosis,
as it reduces endometriosis-associated pain
and improves quality of life

38. Hysterectomy
• Hysterectomy with removal of the ovaries
and all visible endometriosis lesions
1. in women who have completed their family
2. failed to respond to more conservative
treatments.
.
Women should be informed that
hysterectomy WILL NOT
necessarily cure the symptoms or the disease.

39. Surgical interruption of pelvic nerve pathways.
• Clinicians should not perform laparoscopic
uterosacral nerve ablation (LUNA)
• Clinicians should be aware that presacral
neurectomy (PSN) is effective to reduce
endometriosis-associated midline pain,
but it requires a high degree of skill and is a
potentially hazardous procedure

40. Are preoperative hormonal therapies effective
for treatment of pain?
• Clinicians should not prescribe preoperative
hormonal treatment to
improve the outcome of surgery for pain in
women with endometriosis

41. Are short-term post-operativeAre short-term post-operative
hormonal therapies effective forhormonal therapies effective for
treatmenttreatment
of pain?of pain?
?
BIGQUESTIONNO.8BIGQUESTIONNO.8

42. AFTER SURGERY
ADJUNCTIVE SHORT TERM
<6 MONTHS
Secondary Prevention
> 6months
NOT ADVOCATED SIGNIFICANT ROLE

43. Is there a role for secondaryIs there a role for secondary
prevention of disease and painfulprevention of disease and painful
symptoms in women treated forsymptoms in women treated for
endometriosis?endometriosis?
?
BIGQUESTIONNO.9BIGQUESTIONNO.9

44. Secondary Prevention
• Interventions to prevent the recurrence of pain
symptoms or the recurrence of disease in the long-
term, defined as more than 6 months after surgery.
• The GDG states that there is a role for prevention of
recurrence of disease and painful symptoms in
women surgically treated for endometriosis.
• The choice of intervention depends on patient
preferences, costs, availability and side effects.

45. • In women operated on for an endometrioma (≥3
cm),
Ovarian Cystectomy,
instead of drainage and electrocoagulation
• After cystectomy in women not immediately
seeking conception, prescribe combined
hormonal contraceptives
Secondary Prevention of Ovarian
Endometrioma

46. • Post-operative use of a LNG-IUS or a
combined hormonal contraceptive for at
least 18–24 months,
SECONDARY PREVENTION
OF ENDOMETRIOSIS
Endometriosis-associated dysmenorrhoea,
not for non-menstrual pelvic pain or Dyspareunia

47. Extragenital EndometriosisExtragenital EndometriosisBIGQUESTIONNO.10BIGQUESTIONNO.10

48. • Surgical removal of symptomatic extragenital
endometriosis, when possible, to relieve
symptoms
• When surgical treatment is difficult or
impossible,
Medical treatment of extragenital
endometriosis to relieve symptoms
EXTRAGENITAL ENDOMETRIOSIS

49. CASE STUDY
Our Experience at Lifecare
• CASE 1
• A 19 old girl with pain abdomen.
• P/A – a mass upto 16 weeks.
• USG – Bilateral Ovarian endometrioma

50. • Patient and parents counselled
1. Modality of treatment – NEEDS SURGERY
2. Loss of Ovarian tissue
3. Recurrence ( 20% in 2 years, 50% in 5 years)
• Underwent laproscopy bilateral cystectomy.
• Put on combined continuous oral contraceptives.
• Two year follow up – no recurrence.

51. Case 2
• 26 year old , P2 , does not want a child
• Dysmenorrhea and dyspareunia.
• P/V – fixed retroverted uterus, tender
• TVS – adherent ovaries , restricted mobility
adenomyosis

52. • Treatment Offered:
Laparoscopy with ablation of deposits and
adhesiolysis
• Mirena inserted at same sitting
• Patient is asymptomatic at 1 year follow up.

53. TAKE HOME MESSAGE
• High Suspicion of Endometriosis
• Emperical Medical Treatment can be started
without confirmation by Laproscopy
• Laproscopy with histology is the gold
standard.
• Always SEE and TREAT on Laproscopy
• Use modalities for Secondary Prevention after
surgery

54. Thank You !!!

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