Endometriosis Max Brinsmead MB BS PhD May 2015

Historical Perspective 1970’s “A disease of uncertain aetiology whose relevance to fertility is uncertain” 1980’s “A common condition that may be present in as many as one woman in four” 1990’s Much more known about aetiology. Principles of management emerging Evidence-based management

Endometriosis is: Ectopic endometrium i.e. “internal menstruation” Requires laparoscopy +/- biopsy for diagnosis Activity is more important than appearance Symptoms do not always correlate with grading

Symptoms of Endometriosis The Classic Triad… Dysmenorrhoea Dyspareunia Infertility

Symptoms of Endometriosis But consider also… Pre menstrual staining Pain with defaecation during menstruation Intermenstrual pain Disordered cycles Family history

Diagnosis of Endometriosis A Careful History (The most important) Rule out other Causes of Symptoms (The next most important) Examination (not much help) Ultrasound (of little value) MRI (useful for rectovaginal deposits) Laparoscopy (The gold standard) Serum CA125 (Lacks sensitivity) Iridology (a good guess!)

Differential Diagnosis: Primary Dysmenorrhoea Irritable Bowel Syndrome Ovulation Pain Pelvic Inflammatory Disease Psychosexual Problems

Aetiology Two Main Theories: Retrograde menstruation Peritoneal metaplasia Predisposing Factors Familial predisposition Disordered immunity Environmental toxins Recurrent ovulation Infertile partner Obstructed menstrual flow

Principles of Management: When the Problem is Pain – Use Medical Rx When the Problem is Infertility – Use Surgical Rx When there is no Problem – Use no Rx

Medical Therapy Options Progestins COC (best in continuous form) Provera or Norethisterone The Mirena IUS Danazol & Gestrinone GnRH agonists +/- Add Back Therapy A question of side effects

Cochrane Conclusions Oral & rectal Chinese Herbal Medicine better than Danazol in both pain reduction and shrinkage of masses Auricular acupunture effective in pain relief Inconclusive evidence that NSAIDs are any better than pacebo But side effects certainly can occur

Cochrane Conclusions(2) COC as effective as GnRHa in control of dysmenorrhoea 6m after therapy but GNRHa better in terms of dyspareunia Oral Provera 100 mg daily more effective than placebo (but not Dyhydrogesterone). IM route no better GnRHa are no more effective than Danazol and side effects are more frequent

Cochrane Conclusions(3) Laparoscopy with diathermy is more effective than just laparoscopy For up to 12m after for pain For conception (OR 1.66, CI ) There is no advantage from pre operative medical Rx but one small trial showed less pain if a Mirena is provided after surgery (OR 0.14, CI ) There is a risk of symptom recurrence if HRT with E2 is used after pelvic clearance

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