Management of endometriosis Tarafdari, Ob/ Gyn, Fellowship in IVF & Infertility

incidence Endometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterus. 6-10% of women of reproductive age 38% in infertile women VS 5% of fertile women 71-87% of women with chronic pelvic pain No particular racial predisposition A familial association Polygenic-multifactorial mechanism of inheritance

Disease progression ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE. SPONTANEOUS REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES.

etiology The pathogenesis of endometriosis Altered endometrial genes Implantation from retrograde menstruration Hematogenous or lymphatic transport of stem cells from bone marrow Coelomic metaplasia Altered endometrial genes Increased COX-2 activity Increased aromatase activity Progestrone resistance

Mechanism of Pain Chronic inflammatory response TNF-a , IL-1,6,8 PGs pain Nerve growth factor especially in rectovaginal lesions increased density of nerve fibers. Altered uterus innervation severe dysmenorrhea

Mechanism of infertility The mechanism by witch it occurs in early stage is unclear. An abnormal peritoneal environment due to oxidative stress & inflammatory cytokines may lead: Affect sperm function & DNA damage Cause abnormalities in oocyte cytoskeleton function AMH is decreased in early stage of endometriosis

Risk factors Early menarche (before age 11) Cycles shorter than 27 days Prolonged & heavy cycles Single/nulliparous Non oral contraception

Protective factors High pariety Increased duration of lactation Regular exercise more than 4 hours per week Smoking

Clinical manifestation The clinical manifestation of endometriosis are variable & unpredictable in both presentation & course. A significant of women remain asymptomatic. Endometriosis should be suspected in women with subfertility, dysmenorrhea, dyspareunia, or chronic pelvic pain. Local symptoms can arise from rectal, ureteral, and bladder involvement.

pain Pelvic pain that is typical in endometriosis is characteristically described as: Secondary dysmenorrhea Deep dyspareunia Sacral backache during menses In adult women, dysmenorrhea may be especially suggestive of endometriosis if it begins after years of pain-free menses. Dysmenorrhea often starts before the onset of menstrual bleeding and continues throughout the menstrual period.

pain The pain associated with endometriosis may not correlate with the stage of disease but there may be some association with the depth of infiltration of endometriotic lesions. Painful defecation during menses and severe dyspareunia are the most predictable symptoms of DIE.

CLINICAL EXAMINATIONS Recommended that pelvic examination be performed at the time of menses when tenderness is easier to detect. The vulva, vagina, and cervix should be inspected for any signs of endometriosis, although the occurrence of endometriosis in these areas is rare(e.g., episiotomy scar). The uterus is often in fixed retroversion, and the mobility of the ovaries and fallopian tubes is reduced. Other possible signs of endometriosis include uterosacral or cul-de-sac nodularity, cervical displacement due to uterosacral scarring , painful swelling of the rectovaginal septum, and unilateral ovarian (cystic) enlargement.

DIAGNOSIS The definitive diagnosis of endometriosis only can be made by histology of endomeriotic lesions removed at surgery. Neither biomarkers nor imaging studies have been able to supplant diagnostic laparoscopy for diagnosis. During diagnostic laparoscopy, the pelvic and abdominal cavity should be systematically investigated for the presence of endometriosis. The visual appearance of lesions during laparoscopy is variable. Classical lesions: black powder-burns lesions Non-classical : red or white lesions CA125 as a diagnostic marker for endometriosis has limited value.

Laparoscopic view of peritoneal lesion Characteristic findings include typical (“powder-burn,”“gunshot”) lesions on the serosal surfaces of the peritoneum. These are black, dark brown, or bluish nodules or small cysts containing old hemorrhage surrounded by a variable degree of fibrosis. Scarring of perotoneum causes adhesions Endometriosis can appear as subtle lesions ,including red implants (petechial, vesicular, polypoid, hemorrhagic, red flamelike), serous or clear vesicles, white plaques or scarring, yellow-brown discoloration of the peritoneum, and subovarian adhesions.

ASRM CLASSIFICATION Is not a good predictors of pregnancy after treatment Does not correlate well with the symptoms of pain & dyspareunia & infertility.

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