1. Dr. Hima Kandimalla Mount Hope Women’s Hospital Trinidad & Tobago
Endometriosis
Dr. Hima Kandimalla
Mount Hope Women’s Hospital
Trinidad & Tobago

2. Endometriosis
Presence of endometrial glands & stroma outside the endometrial cavity and uterine musculature

3. Endometriosis Globally 90 million suffering with Endometriosis
Epidemiology
Globally 90 million suffering with Endometriosis
Prevalence: 3-10% of reproductive age group & 25-35% of infertile women
Peak incidence: yrs of age
Prevalence is similar in all races

4. Endometriosis
sites

5. Endometriosis Implantation or Metastatic theory - Sampson, 1927
Pathogenesis
Implantation or Metastatic theory - Sampson, 1927
Retrograde menstruation
More common in young girls with
genital outflow obstruction
Physiological phenomenon
– Halme et al, AJOG, 1984

6. Endometriosis 1. Alteration in the Endometrium Retrograde menstruation
? Contributing factors
1. Alteration in the Endometrium
2. Altered Immune response
3. Favorable Peritoneal environment
Mechanical – Endometriotic foci in surgical scars
Lymphatic or Hematogenous – Extragenital locations

7. Endometriosis Metaplasia theory – Meyer, 1919
Metaplastic changes in coelomic membrane towards endometrial like tissue following prolonged irritation or Oestrogen stimulation

8. Endometriosis Genetic, Immunological & environmental factors
7 times more common in 1°relatives
– Halme et al, 1986 & Sampson et al 1980
More common in Monozygotic twins than in Dizygotic twins – Simpson et al, 1984
Decreased cellular immunity to endometriotic tissue Dmowski et al, 1981
? Dioxins – Endometriosis association, 1993

9. Endometriosis Mechanical Endocrine Immunological Genetic Implantation
Metaplasia
Endometrial implant
Progression &
invasion
Lymphatic &
Blood spread
Adapted & Modified from – R.W. Shaw, Gynecology

10. Endometriosis Pathology Puckered black lesions White scarring
Red polyps
Clear blebs

11. White plaques &
Clear vesicles
Blue-black
lesions
Newly formed
blood vessels

13. Endometriosis Endometrioma Pathology
Contains blood, fluid & menstrual debris
Brown to black color due to Hemosiderin

14. Endometriosis Microscopy Pathology Endometrial glands & stroma
Often contain fibrous tissue, blood & cysts

15. Endometriosis Stromal endometriosis
Implants contain only stromal component without glandular part
Not hormonal dependent
Locally malignant

16. Endometriosis Staging Stage I – Minimal Stage II – Mild
– American society of Reproductive Medicine, 1996
Stage I – Minimal
Isolated superficial implants,
No adhesions
Stage II – Mild
More superficial implants (<5cm),
No significant adhesions

17. Endometriosis Staging Stage III – Moderate Stage IV – Severe
– American society of Reproductive Medicine, 1996
Stage III – Moderate
Multiple superficial & invasive implants,
Peritubal & Periovarian adhesions may be present
Stage IV – Severe
Multiple implants,
Ovarian endometriomas,
Many dense adhesions

18. Endometriosis Staging
– American society of Reproductive Medicine, 1996
Staging is designed to predict the likelihood of future fertility
There is no correlation between the stage of disease & the degree of pain or the prognosis with treatment

19. Endometriosis Diagnosis Often misdiagnosed
The average time to diagnosis is 9.28 years
– Endometriosis association study, 1998
Delay in diagnosis:
- Progression of symptoms
-  Infertility till complete reproductive failure

20. Endometriosis Reproductive organs Symptoms Dysmenorrhoea
Lower abdominal, pelvic & low back pain
Menstrual irregularities
Infertility

21. Endometriosis GIT Symptoms Cyclical rectal bleeding Tenesmus Dyschesia
Diarrhea/ Cyclic constipation
Image courtesy of Dr. Andrew Cook. Visit his site: Endometriosis

22. Endometriosis Urinary tract Symptoms Cyclical hematuria
Cyclical dysuria
Ureteric obstruction

23. Endometriosis Lungs Symptoms Cyclical hemoptysis
Blood stained Pleural effusions
Catamenial Pneumothorax
Haemothorax & ascites associated with endometriosis. - Charran D, Roopnarinesingh S. Department of Obstetrics and Gynaecology, U.W.I., Trinidad. West Indian Med J Mar;42(1):40-1.

24. Endometriosis Umbilicus & Surgical scars Symptoms
Cyclical pain & swelling

25. Endometriosis Pelvic pain Infertility Dyspareunia
Symptoms
Dysmenorrhoea
Pelvic pain
Infertility
Dyspareunia
Menstrual irregularities
Cyclical dysuria / hematuria
Dyschesia
Cyclic Rectal bleeding
60-80%
30-50%
30-40%
25-40%
10-20%
1-2%
<1%

26. Endometriosis Signs Pelvic tenderness. Fixed retroverted uterus.
Nodularity of the Douglas pouch and uterosacral ligaments.
Ovaries may be enlarged and tender . Ovarian cyst may be detected.

27. Endometriosis Infertility
Clear association with infertility has not been established
Incidence of endometriosis in general population of reproductive age : 2-10%
- Barbieri et al, 1990
Incidence of endometriosis in infertile women: 20-40%
Mahmood et al, 1990

28. Endometriosis Infertility In early stages:
 Activated macrophages in peritoneal fluid
 PG, IL-1, TNF & proteases in peritoneal fluid
 levels of anti-endometrial antibodies
Luteal phase dysfunction
Abnormal follicle growth
Multiple premature LH surges
LUF syndrome

29. Endometriosis Infertility In advanced stages:
Pelvic adhesions impairs ova release, blocks sperm entry into the peritoneal cavity & inhibits tubal pickup of the oocyte

30. Endometriosis Risk of cancer
Ovarian Clear cell & Endometrial cell carcinomas
Breast cancer, Melanoma & NHL
- Endometriosis Association study, 1998

31. Endometriosis Differential diagnosis Pelvic infection Uterine Myomas
Ovarian malignant tumors with metastatic deposits in the pouch of Douglas
Acute abdomen
Rectal carcinoma

32. Endometriosis Laparoscopy Investigations
‘Gold standard’ diagnostic test for endometriosis
It permits a “see & treat” approach, although its effectiveness may be limited by the nature of the disease and the surgeon's skill

34. Endometriosis Serum CA 125 Investigations
Sensitivity 28% & specificity 90%
- Mol BW et al, Fertil Steril, 1998
Not useful for screening, because of poor sensitivity
Can be used to identify a sub-group of women who are likely to benefit from early laparoscopy & to follow the progress of disease after establishing the diagnosis I 19 II 40
III 77 IV
182
- Cheg YM et al, Obst Gyn, 2002

35. Endometriosis Ultrasound Investigations
Sensitivity for focal endometrial implants is poor

36. Endometriosis Ultrasound Investigations
For Endometriomas sensitivity 83% & specificity 98%

37. Endometriosis CT scan Investigations
Endometriomas may appear solid, cystic or mixed
Because of poor specificity & high radiation, CT has been replaced by MRI

38. Endometriosis MRI Investigations
Role is limited in visualizing small endometriotic implants and adhesions
More useful for lesions in extraperitoneal locations & the contents of pelvic mass
More frequently used in staging & treatment response monitoring

39. Endometriosis
Treatment
Consider
Age
Symptoms
Stage
Infertility

40. Endometriosis Treatment Rationale Recognize Goals:
– Pain Management
– Preservation / Restoration of Fertility
Discuss with Patient:
– Disease may be Chronic and Not Curable
– Optimal Treatment Unproven or Nonexistent

41. Endometriosis
Lines of management
Expectant
Medical
Hormonal
Surgical

42. Endometriosis Expectant management
Young , asymptomatic infertile patient with mild endometriosis.
If pregnancy does not achieved within months of observation, hormonal or surgical treatment is indicated .

43. Endometriosis Medical Treatment
Symptomatic pts with minimal or mild lesions
NSAIDs
Opioids.

44. Endometriosis Hormonal Treatment
Produces pseudo pregnancy or pseudo menopause
Danazol
Progestins
Gestrinone
Combined oestrogen-progestogen Pills
GnRH agonists.

45. Endometriosis Indications Hormonal Treatment
Small & superficial lesions
Recurrence after conservative surgery
Preoperative for 6-12 wks to decrease size
Postoperative for residual lesions
When surgery is contraindicated or refused by the patient.
Enometriosis in Rectovaginal septum & laparotomy scars doesn’t respond to Hormonal therapy

46. Endometriosis Danazol Causes anovulation by
Isoxazole derivative of 17 – alpha ethinyl testosterone
Causes anovulation by
Attenuating the mid cycle surge of LH
Inhibiting multiple enzymes in steroidogenic pathway
 Testosterone levels
Dose: 400 – 800 mg/ day for 6 months
Adverse effects: Androgenic effects, effects on serum lipids,  Bone mineral density & Liver damage

47. Endometriosis Progestational drugs
Causes endometrial decidualization & atrophy
Medroxyprogesterone (Provera) is commonly used
Dose: mg/ day for 6 -9 months
Adverse effects: Abnormal uterine bleeding, nausea, breast tenderness, fluid retention & depression

48. Endometriosis Gestrinone (Ethylnorgestrienone)
Antiprogestational steroid causes  estrogen & progesterone receptors
Dose: 5-10 mg/ wk - dly or twice a wk or 3 times a wk, for 6-9 months
Adverse effects: deepening of voice, hirsuitism & Clitorial hypertrophy

49. Endometriosis Combined pills
Well tolerated & can be continued for long term
1 pill/ day either continuously or cyclically
Continuous regimen is superior in patients with dysmenorrhea
Adverse effects: weight gain, abnormal bleeding & HTN

50. Endometriosis GnRH agonists
 FSH & LH & results in endometrial atrophy & amenorrhea
Intranasally or SC or IM with a frequency of twice dly to once in 3 months up to months
Adverse effects: transient vaginal bleeding, hot flushes, vaginal dryness,  libido, breast tenderness, insomnia, depression, irritability, fatigue, headache, osteoporosis,  elasticity of skin
GnRH agonists + Add-back therapy (estrogens & progestogen) – less side-effects but with same efficacy, can be continued beyond 6 months

51. Endometriosis Hormonal Treatment
The choice between the COCPs, Progestogens, Danazol & GnRH agonists depends principally upon their side-effect profiles because they relieve pain associated with endometriosis equally well
- Clinical Green Top Guidelines, 2000

52. Endometriosis Surgical management
Conservative – Excision, Cauterization & Evaporation
Surgeries for pain - Uterosacral Nerve Ablation (LUNA), Presacral Neurectomy
Radical surgeries - Hysterectomy +/- BSO
Surgeries for Endometrioma – Cystectomy, Drainage & coagulation, Fenestration

53. Endometriosis Surgical management Laparotomy Vs Laparoscopy
Efficacy is same
Laparoscopy – less cost & shorter recovery time even in women with advanced endometriosis

54. Endometriosis Laparoscopic management 1. Excision 2. Vaporization
3. Fulguration & Desiccation
4. Cystectomy for endomterioma
5. Drainage & Coagulation for endometrioma
6. Fenestration for endometrioma
No RCTs available to compare these procedures
Cystectomy offer better results than drainage & coagulation for Endometrioma
If no cyst wall is present, Fenestration followed by GnRH agonists may prove beneficial

55. Endometriosis
Laparoscopic management

56. Surgical management much better in moderate & severe cases
outcome was poorest in minimal endometriosis
much better in moderate & severe cases
- Sutton CJ et al, Fertil Steril 1994

57. Endometriosis Combination of Hormonal & Surgical
Postoperative Danazol & Medroxyprogesterone for 6 months lowered the pain scores significantly – Telimaa S et al, Gynecol Endo, 1987
Postoperative GnRH agonist for 6 months lowered the recurrence rates but with no change in pain scores – Parazzini F et al, AJOG, 1994
Sufficient data is not available to conclude that hormonal & surgical combination is associated with significant benefits. The possible benefits should be weighed in the context of the adverse effects & costs of these therapies
- Cochrane review, May 2004

58. Endometriosis Infertility Management
No role for medical therapy with hormonal drugs
Laparoscopic ablation of minimal – mild endometriosis may improve fertility rates
- Cochrane review, 2004

59. Endometriosis
IUI
The presence of endometriosis does not generally impair the results of IUI
Ovarian hyperstimulation using Gonadotrophins with IUI is better than no treatment or IUI alone
Nulsen Jc et al, Obst Gyn, 1993 &
Tummon IS et al, Fertil Steril, 1997

60. Pelvic pain & suspected Endometriosis Empirical GnRH agonist +
Treatment
Pelvic pain & suspected Endometriosis
Continue
drug therapy
NSAID or OCP
Success
Failure
Empirical GnRH agonist +
Estro & Prog
add-back therapy
Operative
Laparoscopy
Continue
Drug therapy
Failure
Success
GnRH agonist +
Estro & Prog
add-back therapy

61. Suspected endometriosis
Treatment
Infertility &
Suspected endometriosis
Operative Laparoscopy
Assisted
Reproduction
Pregnancy
Success
Watchful waiting
Failure

62. Endometriosis Conclusion
Endometriosis is a mystery tour as it requires decision making at every stage by the physician and the patient.
Endometriosis still stand as one of the most-investigated disorders in gynecology. So is one of the highest priorities for research.

63. Thank you