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Endometriosis ENDOMETRIOSIS

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<ul><li>I s characterized by the presence of endometrial tissue on the ovaries, fallopian tubes or other sites, causing pain or infertility. </li></ul><ul><li>The disease tends to progress under the repetitive influence of the menstrual cycle I </li></ul>

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<ul><li>Dense adhesions are commonly associated with advanced endometriosis. </li></ul><ul><li>They can be treated with laparoscopy techniques, but are more likely to reform after surgery. </li></ul>

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<ul><li>Minimal adhesions between the left ovary and pelvic sidewall. </li></ul><ul><li>Commonly associated with mild to moderate endometriosis. </li></ul>

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Ovary with endometrioma.

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<ul><li>This picture shows a chocolate cyst, which can be quite common in more advanced endometriosis </li></ul>

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Rupture endometrioma

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Endometriosis! <ul><li>Epidemiology </li></ul><ul><ul><li>> 70 million women and girls have Endometriosis world-wide. </li></ul></ul><ul><ul><li>10 - 20 % of women of reproductive age have Endometriosis. </li></ul></ul><ul><ul><li>It is more common than breast cancer or Aids, and many other diseases, that are well known </li></ul></ul><ul><li>Endometriosis is not usually fatal </li></ul>

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<ul><li>the longer that this disease goes undiagnosed </li></ul><ul><li>the more damage it can do. </li></ul>

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Pathogenesis <ul><li>is not well understood </li></ul><ul><li>is probably multifactorial in origin </li></ul><ul><li>the most widely embraced theory involves retrograde menstruation 5 </li></ul>Retrograde menstruation

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Investigation <ul><li>A definitive diagnosis can be made only by means of laparoscopy </li></ul><ul><li>Imaging tests: ultrasound, MRI, CT, are occasionally used to identify individual lesions </li></ul><ul><li>Biochemical markers </li></ul><ul><ul><li>CA-125 A recent study of this antigen level, showed it to be high in 90 percent of women with Endometriosis </li></ul></ul>

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Stages of Endometriosis <ul><li>B ased on the severity, location, amount, depth and size of growths. </li></ul><ul><li>The stages of the disease do not indicate the level of pain, infertility or symptoms. </li></ul><ul><li>the correlation between stage and extent of disease remains controversial </li></ul>

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Stages of Endometriosis <ul><li>Stage 1 - minimal disease, superficial and filmy adhesions </li></ul><ul><li>Stage 2 - mild disease, superficial and deep endometriosis </li></ul><ul><li>Stage 3 - moderate disease, deep endometriosis and adhesions </li></ul><ul><li>Stage 4 - severe disease, deep endometriosis, dense adhesion </li></ul>

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Classification of Endometriosis ( Modified American Fertility Society System) <ul><li>Base on extent of peritoneum,ovary,tube,cul de sac endometriosis and adhesions </li></ul><ul><ul><li>Stage I Score 1-5 minimal </li></ul></ul><ul><ul><li>Stage II Score 6-15 mild </li></ul></ul><ul><ul><li>Stage III Score 16-40 moderate </li></ul></ul><ul><ul><li>Stage IV Score > 40 Severe </li></ul></ul>

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Classification of Endometriosis 16 8* 4 * Dense 4 2 1 L Filmy 16 8* 4 * Dense 4 2 1 R Filmy Tube 16 8 4 Dense 4 2 1 L Filmy 16 8 4 Dense 4 2 1 R Filmy >2/3enclosure 1/3-2/3 enclosure < 1/3 enclosure Adhesions Ovary

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Classification of Endometriosis 20 16 4 Deep 4 40 partial complete posterior cul de sac obliteration 20 16 4 Deep 4 2 1 L Superficial 4 2 1 R Superficial Ovary 6 4 2 Deep 4 2 1 Superficial >3cm 1-3 cm < 1CM Endometriosis Peritoneum

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Common site of endometriosis

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Endometriosis Symptoms <ul><li>Endometriosis does not follow any distinct pattern </li></ul><ul><li>The symptoms of Endometriosis vary from one woman to another </li></ul><ul><li>T he most common symptom is pelvic pain. </li></ul>

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The most common symptoms <ul><li>Pain before and during periods </li></ul><ul><li>Pain with intercourse </li></ul><ul><li>General, chronic pelvic pain throughout the month </li></ul><ul><li>Heavy and/or irregular periods </li></ul><ul><li>Painful urination during menstruation </li></ul><ul><li>Infertility </li></ul><ul><li>Fatigue </li></ul><ul><li>Low back pain </li></ul><ul><li>Painful bowel movements, especially during menstruation </li></ul><ul><li>Diarrhoea or constipation </li></ul>

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Symptoms relate to endometriosis site <ul><li>Reproductive Endometriosis </li></ul><ul><ul><li>Pelvic pain </li></ul></ul><ul><ul><li>Ectopic (tubal) pregnancy </li></ul></ul><ul><ul><li>Dysmenorrhea </li></ul></ul><ul><ul><li>Infertility </li></ul></ul><ul><ul><li>Miscarriage(s) </li></ul></ul><ul><ul><li>Painful ovulation </li></ul></ul><ul><li>Uterosacral/Presacral Nerve Endometriosis </li></ul><ul><ul><li>Backache </li></ul></ul><ul><ul><li>Leg pain </li></ul></ul><ul><ul><li>Dyspareunia </li></ul></ul><ul><li>Cul-de-sac (&quot;Pouch of Douglas&quot;) Endometriosis </li></ul><ul><ul><li>Dyspareunia (pain during intercourse) </li></ul></ul><ul><ul><li>Gastrointestinal symptoms </li></ul></ul><ul><ul><li>Pain after intercourse </li></ul></ul>

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<ul><li>Gastrointestinal symptoms of Endometriosis </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Blood in stool </li></ul></ul><ul><ul><li>Bloating </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Rectal pain </li></ul></ul><ul><ul><li>Rectal bleeding </li></ul></ul><ul><ul><li>Tailbone pain </li></ul></ul><ul><ul><li>Abdominal cramping </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Sharp gas pains </li></ul></ul><ul><ul><li>Painful bowel movements </li></ul></ul>Symptoms relate to endometriosis site

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<ul><li>U rinary tract Endometriosis </li></ul><ul><ul><li>Blood in urine </li></ul></ul><ul><ul><li>Painful or burning urination </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Tenderness around the kidneys </li></ul></ul><ul><ul><li>Flank pain radiating toward the groin </li></ul></ul><ul><ul><li>Urinary frequency, retention, or urgency </li></ul></ul>Symptoms relate to endometriosis site

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<ul><li>Pleural (lung & chest cavity) Endometriosis </li></ul><ul><ul><li>Very occasionally </li></ul></ul><ul><ul><li>Coughing up of blood or bloody sputum, particularly coinciding with menses </li></ul></ul><ul><ul><li>Accumulation of air or gas in the chest cavity </li></ul></ul><ul><ul><li>Constricting chest pain and/or shoulder pain </li></ul></ul><ul><ul><li>Collection of blood and/or pulmonary nodule in chest cavity (revealed under testing) </li></ul></ul><ul><ul><li>Shortness of breath </li></ul></ul>Symptoms relate to endometriosis site

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Symptoms relate to endometriosis site <ul><li>Skin Endometriosis </li></ul><ul><ul><li>Painful nodules, often visible to the naked eye, at the skin's surface. Can bleed during menses and/or appear blue upon inspection. </li></ul></ul><ul><li>Sciatic Endometriosis </li></ul><ul><ul><li>Hip pain </li></ul></ul><ul><ul><li>pain that radiates from the buttock and down the leg </li></ul></ul>

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Differential diagnosis by symptoms <ul><li>Generalized pelvic pain </li></ul><ul><ul><li>Pelvic inflammatory disease </li></ul></ul><ul><ul><li>E ndometritis </li></ul></ul><ul><ul><li>Sexual or physical abuse </li></ul></ul><ul><ul><li>N eoplasms, benign or malignant </li></ul></ul><ul><ul><li>Ovarian torsion </li></ul></ul><ul><ul><li>P elvic adhesion </li></ul></ul><ul><ul><li>Nongynecologic causes </li></ul></ul>

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Differential diagnosis by symptoms <ul><li>Dysmenorrhea </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><li>Secondary (adenomyosis, myomas, infection, cervical stenosis) </li></ul></ul>

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Differential diagnosis by symptoms <ul><li>Dyspareunia </li></ul><ul><ul><li>Musculoskeletal causes (pelvic relaxation, levator spasm) </li></ul></ul><ul><ul><li>Gastrointestinal tract (constipation, irritable bowel syndrome) </li></ul></ul><ul><ul><li>Urinary tract (urethral syndrome, interstitial cystitis) </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Pelvic vascular congestion </li></ul></ul>

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Differential diagnosis by symptoms <ul><li>Infertility </li></ul><ul><ul><li>Male factor </li></ul></ul><ul><ul><li>Tubal disease (infection) </li></ul></ul><ul><ul><li>Anovulation </li></ul></ul><ul><ul><li>Cervical factors (mucus, sperm antibodies, stenosis) </li></ul></ul><ul><ul><li>Luteal phase deficiency </li></ul></ul>

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Treatment options for Endometriosis There are general points which should be taken into consideration <ul><li>The severity of the symptoms </li></ul><ul><li>The type of symptoms </li></ul><ul><li>The age of the patient </li></ul><ul><li>The desire to get pregnant or not </li></ul><ul><li>Length of treatment </li></ul><ul><li>Coping with side-effects of drug treatment </li></ul><ul><li>Cost </li></ul>

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Treatment options <ul><li>Observation with no medical intervention </li></ul><ul><li>Hormone treatment </li></ul><ul><li>Surgery </li></ul><ul><li>Combined treatment </li></ul>

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Drugs Commonly used <ul><li>GnRH agonists </li></ul><ul><ul><li>inhibit the secretion of gonadotropin a complete block of egg development, estrogen production and menstrual cycle, makes 'menopausal' </li></ul></ul><ul><li>Danazol </li></ul><ul><ul><li>is a mild form of the male hormone testosterone inhibits leuteinizing hormone (LH) and follicle-stimulating hormone (FSH) </li></ul></ul><ul><li>Gestrinone </li></ul><ul><ul><li>It works in much the same way as danazol with similar, but milder, side effects </li></ul></ul><ul><li>Contraceptive pill </li></ul><ul><ul><li>suppress LH and FSH and prevent ovulation </li></ul></ul><ul><li>Progestational Agents </li></ul><ul><ul><li>Depo-Provera </li></ul></ul><ul><ul><li>Progesterone hormone tablets </li></ul></ul><ul><li>The Mirena Coil (IUD with Levonorgestrel ) </li></ul>

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GnRH agonists <ul><li>Gonadotropin-releasing hormone agonist </li></ul><ul><li>leuprolide (Lupron, Eligard) </li></ul><ul><li>buserelin ( Suprefact , Suprecor) </li></ul><ul><li>nafarelin (Synarel) </li></ul><ul><li>histrelin (Supprelin) </li></ul><ul><li>goserelin ( Zoladex ) </li></ul><ul><li>deslorelin (Suprelorin, Ovuplant) </li></ul>

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GnRH antagonist <ul><li>Abarelix (Plenaxis) </li></ul><ul><li>Cetrorelix (Cetrotide), by Serono </li></ul><ul><li>Ganirelix (Antagon), by Organon International </li></ul>

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S urgery <ul><li>Definitive surgery, which includes hysterectomy and oophorectomy, is reserved for use in women with intractable pain who no longer desire pregnancy. </li></ul><ul><li>In less severe cases, one ovary may be retained to preserve ovarian function </li></ul>

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Surgical treatment

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Surgical Treatment Laparoscopic excision of nodular endometrial lesions overlying the rectum Nodular endometrial lesions in the posterior cul-de-sac.

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Surgical vs. Medical Treatment of Endometriosis Effective for pain relief Unlikely to improve fertility Empiric treatment Adverse effects common Decreased initial cost Medical Option for definitive treatment Definitive diagnosis Invasive Possibly better long-term results Expensive Beneficial for infertility Surgical Disadvantages Advantages Treatment <ul><li>Adverse effects common </li></ul><ul><li>Unlikely to improve fertility </li></ul><ul><li>Decreased initial cost </li></ul><ul><li>Empiric treatment </li></ul><ul><li>Effective for pain relief </li></ul>Medical <ul><li>Expensive </li></ul><ul><li>Invasive </li></ul><ul><li>Beneficial for infertility </li></ul><ul><li>Possibly better long-term results </li></ul><ul><li>Definitive diagnosis </li></ul><ul><li>Option for definitive treatment </li></ul>Surgical Disadvantages A dvantages Treatment

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Recurrence Rates <ul><li>a laparoscopically defined cumulative five-year recurrence rate of about 19 percent. </li></ul><ul><li>t he long-term benefit of surgical intervention for pain is enhanced by definitive surgery, including bilateral oophorectomy, with a 10 percent cumulative recurrence after 10 years. </li></ul><ul><li>surgical treatment is the apparently lower recurrence rate compared with medical treatment </li></ul>