endometriosis is a chronic and recurrent disease. Negetively affects women health. Dysmenorrhea treatment can be frustrating

1. Dysmenorrhea -Endometriosis
Veerendrakumar C M MD,DNB
Professor and Unit Head
Dept of OBG, VIMS
Ballari

2. Primary and secondary
Most common cause for signi
fi
cant absenteeism from work, school
absence among adolescents.

3. Profound negative impact on a woman’s day-to-day life
.
Dysmenorrhea is a public health problem associated with substantial economic loss
related to work absences
(an estimated 600 million work hours and 2 billion dollars in the United States).
Am J Med 1984

4. Dysmenorrhea may affect more than 50% of menstruating women, and its reported
prevalence has been highly variable
Hum Reprod Update 201
5
Use of OCP and self Medication with NSAID hinders the correct estimation

5. Endometriosis is a chronic and recurrent disease that adversely affects
quality of life in reproductive age women.

6. gastrointest
endometrio
of Reprodu
cautery of a
ment of the
Althou
tion and im
of endome
the cases o
neither men
review by
may develo
struation an
embryonic
Table 1. Differential diagnosis of primary and second-
ary dysmenorrhea
Primary Secondary
dysmenorrhea dysmenorrhea
Within 3 yr More than 5 yr
Onset
after menarche after menarche
Age 15–25 yr old Over 30 yr old
Aging Gradually improve Become worse
Marriage Improve No change
Postpartum Improve No change
Findings of internal Endometriosis,
examination
Normal
fibroma, etc.
Time Menstruation
Menstruation or
other time if worse
Duration 4–48 h 1–5 d

7. Retrograde menstruation observed in 90% of menstruating women is
considered a key factor in the pathogenesis of endometriosis. (Sampson’s
implantation theory)
Seen in women with late marriage and low parity - reflects change in
lifestyle

8. Incidence
Endometriosis is the most common cause of secondary dysmenorrhea. It has been identified in 62-
75% of adolescents undergoing laparoscopy for CPP and/or dysmenorrhea

9. Genetics
There is a polygenic multifactorial inheritance pattern to endometriosis
Young women with a first-degree affected relative have a 7-10 fold increased risk .
Epigenetic changes may also play a role.
Dovey et al , Clin Obstet Gynecol 2010

10. Implantation hypothesis
Retrograde menses
Coelomic metaplasia
Lymphatic spread
Hematological spread
Immunological

11. Neonatal bleeding -newer hypothesis
Neonatal vaginal bleeding is thought to increase the risk of early-onset endometriosis.
While actual bleeding is observed in 5% of newborn girls, occult bleeding may occur in 25%
At the time of increasing estrogen production (puberty), these endometrial cell clusters are
re-activated
Am J Obstet Gynecol 2013;209:307-316. Epub 2013

12. Pain pathophysiology
Endometriosis is a hormone mediated, neuro-vascular condition
The presence of endometrial tissue incites an estrogen-dependent chronic inflammatory reaction
Pain derives from increased prostaglandins, compression and/or infiltration of adjacent nerves
Increased expression of nerve growth factor, increased density of nerve fibers, angiogenesis and
changes to innervation of the uterus may also contribute
Hum Reprod Update 2011

13. Mechanism of pain in endometriosis
A.Pain due to endometriotic lesions
1.Peritoneal lesions induce inflammatory reactions and secrete prostaglandins, cytokines, histamine and kinin
that cause pain.
2 Deep infiltrating endometriosis destroys tissues and nerves.
3 Ruptured chocolate cysts may irritate peritoneum.
Tasuku H Yonago Acta medica 2013

14. Mechanism of pain in
endometriosis
B Scar and fibrosis, secondary lesions
1 Scar, fibrosis, traction, and adhesion may reduce mobility of organs. Pain may occur during
movement or ovulation.
2 Adhesion of bowel may cause defecation pain or dyschezia.
3 Retroverted uterus due to adhesion,severe adhesion of ovaries to Douglas pouch, and induration
of sacral ligament may cause dyschezia.
Tasuku H Yonago Acta medica 2013

15. • Endometriosi
s
•
Pelvic inflammatory disease (PID)
Ovarian cysts and tumors
Adenomyosis
Cervical stenosis or occlusion
Fibroids
Uterine polyps
Intrauterine adhesions
Congenital malformations (eg, bicornuate uterus or subseptate uterus)
Intrauterine contraceptive device (IUCD), or intrauterine device (IUD)
Transverse vaginal septum
Pelvic congestion syndrome
Allen-Masters syndrome

16. Almost any process that can affect the pelvic viscera
can produce cyclic pelvic pain

17. endometriosis can exist concomitantly with other disease
processes causing dysmenorrhea; this makes the diagnosis even
more dif
fi
cult
.
Levy BS,et al J Fam Pract. 2007

18. Indicators of sec dysmenorrhe
a
Dysmenorrhea beginning in the 20s or 30s, after relatively painless menstrual cycles in the past
Heavy menstrual
fl
ow or irregular bleeding
Dysmenorrhea occurring during the
fi
rst or second cycles after menarche, which may indicate congenital
out
fl
ow obstruction
Pelvic abnormality with physical examination (consider endometriosis, pelvic in
fl
ammatory disease
[PID], pelvic adhesions, and adenomyosis)
Little or no response to nonsteroidal anti-in
fl
ammatory drugs (NSAIDs) or OCs
Infertility
Dyspareunia
Vaginal discharge

19. In the pelvis, there are 3 manifestations of this disease:
1.Endometriomas,
2.Peritoneal endometriosis with or without adhesions
3.Deep infiltrating endometriosis (D I E)
Best Pract Res Clin Obstet Gynaecol. 2014

20. Definitive diagnosis requires histopathological evidence but is invasive and produces considerable
morbidity.
Advent and availability of noninvasive diagnostic methods are important for the work-up and
subsequent treatment of these patients.
Imaging may identify characteristic findings of adenomyosis and endometriosis besides providing
a good degree of diagnostic accuracy.
Also imaging serves as preoperative assessment tool and helps in surgical planning.

21. 4
basic Ultrasound steps
(International Deep Endometriosis Analysis -IDEA
group.)
1.assess the uterus and adnexae
(-r/o adenomyosis and endometrioma and
fi
xity of uterus)
2
.evaluation of ‘‘soft markers’’ for endometriosis
(such as site- speci
fi
c tenderness and
fi
xed ovaries
3
.evaluation of the pouch-of-douglas (POD) using the ‘‘sliding organ’’ sign.
4
. Assessment of DIE nodules in the ant and post compartments
Ultrasound Obstet Gynecol. 2016

22. Endometriomas have a tendency to be multiple, persist in time and remain with a stable appearance, unlike
other adnexal masses
Accordng to a Cochrane meta-analysis, TVUS has a sensitivity and specificity of 95% and 91%, respectively
for the diagnosis of endometriomas The sonographic appearance ranges from an anechoic to a complex cyst
with heterogenous appearance and septations.
Many endometriomas have internal homogenous ground-glass or low-level echoes without
internal color Doppler flow or wall nodule
Clin Obstet Gynecol.
2009;

23. Differentiating from acute hemorrhagic cyst
1. Multi locularity
2. The presence of punctate, peripheral, echogenic foci inside the cyst wall is very specific
there has to be a clear demarcation from the ovarian parenchyma, no intramass vascularization of
the cyst (only exhibiting pericystic flow) and absence of neoplastic features

24. SUPERFICIAL PERITONEAL IMPLANTS AND ADHESIONS
Unlike endometriomas, the sonographic identification of superficial peritoneal implants and adhesions is
difficult
Indirect evidence of the latter can frequently be found by using a modified US technique called the
‘‘sliding organ’’ sign( 83% and 94% sensitivity and specificity)
Adhesions should be suspected in the presence of limited or absent mobility between the pelvic organs,
including the uterus and ovaries, and its surrounding structures
Guerriero S Minerva Gynecol
2013

25. DIE -deep in
fi
ltrating endometriosis
DIE is characterized by the presence of implants which penetrate >5 mm into the peritoneum and
into the retroperitoneal space or wall of the pelvic organs
Sonographically (TVUS), implants will appear as hypoechoic cystic or noncystic nodules with
regular or irregular contours with or without hypoechoic linear thickening.
when endometriosis involves the bowel, lesions appear to have a thinner section (tail) at one end
which resembles a ‘‘comet’’ and called as COMET sign.

26. Newer modalities for DIE
Saline contrast - sono vaginography or sono rectography can be
used to increase the the diagnostic accuracy of endometriosis
involving rectum, USL and vagina .

27. Diagnosis
Visual inspection by laparoscopy or laparotomy is the gold standard for diagnosing endometriosis
Laparoscopy cannot always be performed in daily practice
Therefore, the term, “clinical endometriosis”, is used when only patient history, clinical
examination and ultrasound are available to support the diagnosis.

28. red lesions, most frequently observed in young patients with endometriosis,
may be the cause of pain…

29. no correlation has been found between severity of pain symptoms and stage of the disease or site
of the endometriotic lesions
However Laparoscopic resection or cautery of the lesions improve symptoms in over 80% of
patients.

30. Peritoneal defects or windows, which are also diagnostic of endometriosis, are reportedly very
common in adolescents.
Such lesions are difficult to be diagnosed by laparoscopy
Improved visualization and identification can often be obtained by increasing the laparoscopic
magnification.
Läufer MR, Gynecol Obstete Invest. 2008

31. Clinical presentation
Severe dysmenorrhea associated with missed activities should raise the suspicion of endometriosis.
“classical” symptoms: dysmenorrhea, dyspareunia, dyschezia, endometriomas, and/or infertility.
Common symptoms in young women with endometriosis include general pelvic pain, low energy and abdominal
discomfort.
Heavy menstrual bleeding, headaches, dizziness, low back pain are also more prevalent.
Bloating, constipation, diarrhea, nausea, pain with defecation and pain that improves after bowel movements
Best Pract Res Clin Obstet Gynaecol 2004

32. Laparoscopy for diagnosis only, without a trial of medical treatments, should be avoided
If laparoscopy is undertaken, concurrent treatment of endometriosis should be performed
J Obstet Gynaecol Can 2017

33. Management
Endometriosis is a chronic disease. As in primary dysmenorrhea, first-line treatment includes
analgesia and hormonal therapy.
Endometriosis is an estrogen-dependent disease; most therapies are aimed at supressing ovarian
function
ESHRE guideline, Hum Reprod 2014

34. NSAIDS
Non-steroidal anti-inflammatories (NSAIDs) are the preferred first line analgesics; regular use has shown a
27-35% improvement in dysmenorrhea
No specific NSAID is superior
Patient counselled to start with twice the regular dose followed by regular dosing
If menses can be predicted, NSAIDS should be started 1-2 days prior
Women who experience significant neurological or gastrointestinal side effects should be offered selective
COX-2 inhibitors.
Expert Opin Pharmacother
2012

35. Hormones
Combined hormonal contraception (CHC) - who fail NSAIDs and/or require contraception
CHC may also be used as a first line option
CHC improve dysmenorrhea by reducing endometrial growth, menstrual fluid volume, and prostaglandin and leukotriene
Ovulation inhibition and endometrial thinning
CHC improve dysmenorrhea and reduce missed activities, and can safely be taken cyclically or continuously
Multiple studies have demonstrated improvement in dysmenorrhea with extended or continuous compared to cyclic
regimens
Progestin-only options if contraindications to CHC are present.
Levonorgestrel-releasing intrauterine systems (LNG-IUS) have been shown to improve both primary and secondary
dysmenorrhea
LNG-IUS are safe to use in adolescent and nulliparous women
ACOG Committee Opinion No. 760.

36. CHC
CHC are an ideal first choice due to documented safety, efficacy, low side effect profile and low
cost
No CHC is superior
Endometrioma formation and recurrence are reduced through CHC- associated anovulation

37. Complimentary
Non-medical interventions including heat, traditional Chinese medicine, acupuncture/acupressure,
transcutaneous electrical nerve stimulation (TENS), yoga, and exercise can be offered…
J Obstet Gynaecol Can 2017

38. Progesterone
12
DMPA can be used safely in adolescents. Users experience
improvement in endometriosis and CPP symptoms (56).
DMPA suppresses ovulation and leads to amenorrhea
by inducing endometrial atrophy. Amenorrhea rates are
shoul
endom
until
occur
forms
(20).
LH an
bleed
with
be a
transi
Norethindrone acetate 5-15 mg daily
Medroxyprogesterone acetate 30-50 mg daily
Dienogest 2 mg daily
Depot medroxyprogesterone acetate 150 mg IM q 12 wk
wk: week, IM: intramuscular

39. Progestins have anti-angiogenic, immuno modulatory and anti-inflammatory effects
Medication should be started at lowest dose and increased until menstrual suppression is achieved.
Dosage adjustment and compliance is required .
Progestin-related side effects may be more common in oral regimens

40. Depot medroxyprogesterone acetate (DMPA) and LNG-IUS are more effective at achieving
menstrual suppression compared to oral regimens
LNG-IUS and GnRHa (leuprolide acetate), both demonstrate improvement in pain
Reduced recurrence of pain post-surgery is seen with LNG-IUS
It is safe to use in adolescent and nulliparous women with 96% success at insertion
The American College of Obstetricians and Gynecologists recommends consideration of
LNG-IUS placement at the time of laparoscopy for any patient with dysmenorrhea, chronic pain,
or both

41. Dienogest
equivalent to GnRHa in reduction of dysmenorrhea, dyspareunia, physical symptoms and signs of
endometriosis and improvement in daily activities
Int J Gynaecol Obstet 2012

42. Gestrinone -anti progesterone
When compared to GnRHa, gestrinone was not as effective at six months, but more effective at 12
months

43. GnRHa
GnRHa improve endometriosis-related pain by inducing a hypogonadic-state via suppression of the hypothalamic-
pituitary-ovarian axis
Side effects include hot flushes, vaginal dryness, sleep disturbance, headaches, mood changes and bone loss
Studies in the adult population suggest addition of letrozole or tamoxifen may reduce these symptoms.
GnRHa use in adolescents should be considered second line, after inadequate response to hormonal treatment.
Delay use of GnRHa at least till age of 18 years.
A “GnRHa flare” can occur due to an initial surge of LH and FSH, resulting in increased pain and unscheduled
bleeding.
To prevent flare, the initial dose should be timed with the late luteal phase
Curr Opin Obstet Gynecol
2013;

44. Other medical options
Androgens and anti androgens - limited role
Anti androgens - ESHRE suggests that AI should only be considered after hormonal treatment
failure

45. Surgery
•Surgery should be considered after treatment failure extending to 3-6 months.
•The American College of Obstetricians and Gynecologists recommends consideration of
LNG-IUS placement at the time of laparoscopy for any patient with dysmenorrhea, chronic pain,
or both
•

46. Surgical intervention should only be attempted if the patient has severe
symptoms and benefits of pain relief outweigh the risks of surgery.

47. Endometriotic implants cause underlying fibrosis and distortion of adjacent
anatomy.

48. Laparoscopic ablation or resection of endometrial implants must be done with
caution and a careful understanding of the anatomical structures involved.
Occurrence of associated adhesions often present with endometrial implants
that can distort normal anatomy and make visualization challenging.

49. Endometrioma
Surgical technique of laparoscopic removal of the endometrioma involves
• cyst drainage,
• excision (stripping technique),
• fulguration or ablation of cyst wall.
Drainage alone is no longer a recommended treatment modality due to the high prevalence of
recurrence.

50. Cyst wall excision is preferred to the fenestration and ablation technique due to
decreased risk of re-operation with excision.
Excision also decreases post-operative dysmenorrhea, dyspareunia and non-
cyclic pelvic pain
Am J Obstet Gynecol. 2006

51. A five-year follow up study by Healey et al of ablative versus excisional
technique did show significant reduction in deep dyspareunia with excision
over ablation at multivariate analysis
J Minim Invasive Gynecol. 2014

52. D I E
Surgical management of DIE lesions can be more tedious and complex than treatment of
peritoneal endometriosis
Landmarks of excision should include the ureters, uterine arteries, hypogastric nerves, and the
rectosigmoid. Careful dissection must be done so as to not enter rectal mucosa or vaginal
cavity.
Pain free improvement was shown at up to 24 months following surgical intervention
compared to expectant management in regards to dysmenorrhea
Hum Reprod. 2003

53. Centini et al showed that laparoscopic removal of DIE lesions produced an overall
pregnancy rate of 60%
J Minim Invasive Gynecol. 2015

54. Combined surgical and medical management of endometriosis implants have been shown to
decrease implant recurrence rates and improve pain relief
Journal of Minimally Invasive Gynecology. 2013
Definitive management for endometriosis sequelae is removal of bilateral ovaries.

55. Surgery can remove healthy ovarian tissue and decrease follicle count.
Electrocautery for hemostasis can cause ovarian cortical inflammation and
fibrosis.
A skilled surgeon must decide the appropriate means of resection or ablation of
endometriotic implants and
removal of endometriomas to best preserve the patients future fertility
capacity and alleviate the patient’s pain symptoms.
Clin Obstet Gynecol. 2017

56. Surveillance
Endometriosis worsens with ongoing menstruation, and patients should be counselled on
menstrual suppression until pregnancy is desired
Fertility rates are improved in women treated with hormone treatment and/ or surgery
overall incidence of ovarian cancer is low.
increased association with ovarian cancer, specifically endometrioid and clear cell histology types
Hum Reprod 2014

57. Management of endometriosis is often dictated by personal convictions of physicians (and
patients) and by local diagnostic–therapeutic paths and expertise (or lack of ), rather than by robust
evidence derived from adequately designed and conducted pragmatic, randomized, controlled
trials (RCT) diagnostic and treatment modalities for similar clinical conditions vary widely,
exposing women with endometriosis to the risk of several potential harms, including those
deriving from medical overuse.

58. Human Reproduction Open, pp. 1–15, 2019
doi:10.1093/hropen/hoz009
OPINION
When more is not better: 10 ‘don’ts’ in
endometriosis management. An ETIC∗
position statement
ETIC Endometriosis Treatment Italian Club†
*Correspondence address. Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic University of Siena,
Viale Bracci, 53100 Siena, Italy. Tel. +39 335.357096; E-mail: errico.zupi@gmail.com https://orcid.org/0000-0003-0735-6301
Submitted on August 13, 2018; resubmitted on December 9, 2018; editorial decision on March 1, 2019
Downloaded
from
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59. 1.Do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in
infertile women without pelvic pain symptoms
(quality of the evidence, high : strong suggestion)
Do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of
improving the likelihood of conception in infertile patients scheduled for IVF
(quality of the evidence, high; strong suggestion )

60. 3.Do not recommend controlled ovarian stimulation and IUI in
infertile women with .
endometriosis at any stage
(quality of the evidence, moderate; weak suggestion)
4.Do not remove uncomplicated deep endometriotic lesions in
asymptomatic
women, and also in symptomatic women not . seeking conception
when medical treatment is effective and well tolerated
(quality of the evidence, moderate; weak suggestion)

61. Do not leave women undergoing surgery for ovarian endometriomas and not seeking
immediate conception without post-operative long-term treatment with estrogen–
progestins or progestins
(quality of the evidence, high; strong suggestion)

62. Do not perform laparoscopy in adolescent women (<20 years) with moderate–
severe dysmenorrhea and clinically suspected early endometriosis without prior
attempting to relieve symptoms with estrogen–progestins or progestins
(quality of the evidence, low; weak suggestion)

63. Do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost
issues as
fi
rst-line medical treatment, unless estrogen–progestins or progestins have been proven
ineffective, NOT tolerated, or contraindicated
(quality of the evidence, high; strong suggestion)

64. PRIMUM NON NOCERE
Providing high-value care, avoiding medical overuse, and reducing the burden
of treatment should be the main goals of physicians caring for women with
endometriosis.
In the absence of sufficiently robust data supporting the performance of
specific diagnostic and treatment interventions, the priority remains ‘first, do
no harm’.

65. THANK YOU