Treatment of pelvic pain due to endometriosis Dr zahra asgari Associated professor of ob/gyn Endosurgeury Dr.zahra.asgari@gmail.com Arash hospital

TREATMENT Expectant management Medical management Surgical management

Expectant management is considered for two groups of patients: women with no or minimal symptoms perimenopausal women.

MEDICAL TREATMENT   pelvic pain and suspected endometriosis  empiric medical therapy prior to establishing a definitive diagnosis by laparoscopy analgesics and/or combined oral estrogen-progestin contraceptives for women with no more than mild pelvic pain GnRH agonist for those with moderate to severe pelvic pain.

80 to 90 percent of patients some improvement in symptoms with medical therapy medical interventions neither enhance fertility nor diminish endometriomas or adhesions women with suspected endometriomas and advanced stages of disease, or infertility, are more appropriately managed surgically

Surgical management of pelvic pain due to endometriosis

INDICATIONS(diagnosis and management ) ●Failure of medical therapy or contraindications to medical therapy ●Need for a definitive diagnosis of endometriosis (definitive diagnosis requires surgery to visualize and/or biopsy lesions) ●Exclude malignancy in an adnexal mass ●Treatment of infertility in selected women ●Obstruction of the urinary tract or bowel

SURGICAL PLANNING should be counseled about their options They should be counseled about the choice between conservative or definitive surgery( conservative treatment procedures are performed laparoscopically, but extensive disease may require laparotomy)

Conservative versus definitive surgery Conservative surgery is typically used as the initial surgical treatment for endometriosis(excision or ablation of endometriotic lesions with the intent of preserving the uterus and as much ovarian tissue as possible), nerve transection procedures Women with recurrent symptoms may be treated with either repeat conservative surgery or definitive surgery.(hysterectomy combined with bilateral salpingo-oophorectomy) women wish to preserve reproductive and endocrine function, and thus, hysterectomy alone or hysterectomy plus unilateral salpingo-oophorectomy is often performed for pain caused by endometriosis

The choice between conservative and definitive surgery efficacy and potential morbidity of the procedure the patient’s plans for future childbearing and patient preference. Definitive surgery is typically performed after medical therapy and one or more conservative procedures have failed(decide whether to remove or conserve the ovaries)

Conservative surgery advantages :effective( at least in the short term) associated with less morbidity than definitive surgery disadvantage :rate of recurrent symptoms is higher than for definitive surgery

definitive surgery : perioperative complications and recovery hormonal function and body image hysterectomy is associated with a higher complication rate than laparoscopic treatment of endometriosis Some women who undergo hysterectomy may experience regret or a change in body image

In terms of efficacy, in the short term, conservative surgery and hysterectomy appear comparable rate of reoperation for recurrent pain at one year after either laparoscopic treatment or hysterectomy was similar (0 to 5 percent)

it appears that hysterectomy alone is an effective treatment for pain symptoms of endometriosis. Oophorectomy likely increases the efficacy of definitive surgery, but is also accompanied by the quality of life issues and potential adverse health effects of premature menopause There are no data to establish a specific age threshold for which the benefit of oophorectomy for treatment of endometriosis pain outweighs the risks of premature menopause

counsel all women undergoing definitive surgery about the risks and benefits of oophorectomy we tend to discourage oophorectomy in women younger than 40 years Women approaching the average age of menopause (51 years) are more likely to choose oophorectomy since they may reduce the risk of recurrent pain symptoms while losing fewer years of hormonal function

Suspicion of deep infiltrating lesions or extrapelvic disease DIE: refers to lesions that penetrate to a depth of 5 mm or more multifocal and may involve the uterosacral ligaments, rectovaginal space, bowel, ureteral and/or bladder deep infiltrating endometriosis occurred without disease at other sites in only 6.5 percent of patients DIE is suspected based on symptomatology (eg, dysuria, dyschezia, hematochezia) and/or physical examination (eg, uterosacral ligament tenderness with dense nodules, non-mobile uterus)

recommendations regarding conservative and definitive ●Conservative surgery is the first-line option for most women planning surgical treatment of endometriosis

continue suggest hysterectomy rather than conservative surgery ONLY for women with persistent bothersome symptoms of endometriosis who do not plan future childbearing and who have both failed medical therapy and at least one conservative treatment procedure Definitive surgery is also reasonable for women who have additional indications for hysterectomy

For women undergoing hysterectomy for treatment of endometriosis►bilateral salpingo-oophorectomy ONLY for those who value decreasing the risk of reoperation more than avoiding the risks of premature menopause preference for oophorectomy ► woman approaches menopause Oophorectomy is also reasonable for women with extensive disease involving the ovaries.  

the preoperative evaluation should include appropriate additional testing This includes evaluation of the urinary or gastrointestinal tract magnetic resonance imaging (MRI) or rectal sonography may suggest an obliterated pelvic cul-de-sac transvaginal ultrasonography, one can look for the “sliding sign” when placing the probe in the posterior fornix to see if the anterior rectal wall glides smoothly over the retro-cervix. If there is no such sliding observed, then there is a high probability of obliteration of the cul-de-sac by endometriosis

Preoperative medical suppressive therapy Hormonal suppression has been used prior to surgery to decrease the size of endometriotic implants, thereby reducing the extent of surgery required there is no evidence that preoperative hormonal intervention decreases the extent of surgical dissection required to remove implants, prolongs the duration of pain relief, increases future pregnancy rates, or decreases recurrence rates Use of preoperative GnRH agonists reduced disease seen at the time of the second surgery, but there was no evidence that this translated into prolonged duration of pain relief or a decreased recurrence rate

Antibiotic prophylaxis Operative laparoscopy is typically a clean procedure, and antibiotic prophylaxis is not generally used we give prophylactic antibiotics to patients if there is suspicion of adhesive bowel disease, based upon the increased risk of bowel injury

Thromboprophylaxis Use of mechanical or pharmacologic prophylaxis depends upon the procedure and patient risk factors Bowel preparation is not routine in current practice prior to surgery for endometriosis.

Ablation versus excision  The choice of modality is based upon surgeon experience and preference Two randomized trials comparing excision with ablation (monopolar electrosurgery in one trial, diathermic ablation in the other) found no difference in pain scores at 6 to 12 months any difference is likely of trivial clinical significance. There are no high quality data comparing among the various ablative modalities (laser, electrosurgery, ultrasound)

Adhesiolysis adhesive disease; the reported rate is 70 percent in women with and without prior surgery Red lesions are associated with more adhesions than women with only black, white and/or clear lesions , surgery to ameliorate the adhesions is not always effective we perform adhesiolysis selectively We resect all adhesions that may compromise fertility or that correspond to the location of the patient’s pain. Surgical management of DIE requires specialized skills to adequately remove extensive disease The goal is to re-establish normal anatomy

POSTOPERATIVE CARE Postoperative medical therapy : We recommend postoperative medical suppressive therapy for most women treated surgically for endometriosis hormonal therapy increased the duration of pain relief and delayed recurrence of disease postoperative insertion of the levonorgestrel-releasing intrauterine device (LNG IUD) results in decreased dysmenorrhea compared with expectant management first-line therapy is estrogen-progestin contraceptives or oral progestins alone, both of which are easy to tolerate and cost-effective. Another option is a LNG IUD GnRH Hormonal treatment is typically not necessary following oophorectomy. Suppression with a progestin is appropriate if symptoms recur after hysterectomy and oophorectomy Use of a progestin may be contraindicated in women with risk factors for breast cancer.

Postmenopausal hormone therapy after oophorectomy Postmenopausal hormone therapy with low-dose estrogen (equivalent of 0.625 mg conjugated equine estrogens) is not contraindicated in women following an oophorectomy for endometriosis. Treatment may be initiated immediately after surgery the probability of a recurrence in women treated with estrogen therapy is very low (3.5 percent) There is no evidence to support the addition of a progestin to prevent malignant transformation in residual endometriosis lesions or to help suppress growth of such tissue

Repeat surgery  Pelvic pain symptoms often recur after conservative surgical treatment of endometriosis A patient who presents with recurrent pelvic pain following surgical treatment should be evaluated to ensure that the most likely cause is endometriosis If the patient is not on medical therapy, medical therapy should be initiated and other modalities may be helpful (eg, pelvic physical therapy) Surgery may be the only option if a woman has had severe adverse effects from hormonal therapy. For women who have undergone conservative surgery, the patient should be counseled regarding whether to undergo further conservative surgery or definitive surgery