1. ENDOMETRIOSIS WHAT IS THE GENERAL PRACTICE APPROACH?

6. FIRST – A FEW QUESTIONS! IS TREATMENT ALWAYS REQUIRED? WHO NEEDS TREATMENT? DOES ANY TREATMENT REALLY WORK? DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?

7. I DON’T HAVE THE ANSWERS ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE SPON REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

8. HOWEVER---- MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSIS—PERSISTENCE, REGRESSION AND PROGRESSION

9. AND ALSO--------- ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT LAPAROSCOPIC ABLATION OF VISIBLE ENDO IN INFERTILE WOMEN IS ASSOC WITH SIGNIFICANTLY INCREASED FERTILITY RATES THERE IS NO DATA REGARDING EARLY INTERVENTION WRT PREVENTION

13. PREVALENCE NOT PRECISELY KNOWN—2-5% 20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMEN BUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION 52% OF TEENAGES WITH CPP SYNDROME

14. Familial association Relative Risk to siblings 2.3 overall Relative Risk to sibs if severe endo 15

15. Risk factors Single/nulliparous Early menarche Non oral contraception Non smoker shorter cycle/longer duration of flow Dysplastic naevus syndrome, melanoma

16. symptoms 90% severe dysmenorrohoea 70% chronic pelvic pain 75% dyspareunia 55% infertility

17. Infertility mechanisms Adhesions distorsion Increased PGs Cell mediated gamete inj Defective folliculoge nisis Chronic salpingitis Activated macrophag Increased prev. ABs LUFFS Altered tubal motil CytokinesFertilizatio n failure hyperprola ctinaemia Impaired oocyte pick up Sperm phagocyto sed Early spon abortion Luteal phase deficency

19. Treatment of pain NSAIDS: all significantly better than placebo, studies vary which one is best Naproxen >mefanemic acid>aspirin Naproxen=ibuprofen Naproxen only drug with significant SEs

20. treatment of menstrual pain Treatment level of evidence Simple analgesics 1 Herbal remedies 1 alcohol 2 Antidepressants/anxiolytics 2 OCPs 1 NSAIDS 3

21. ENDOMETRIOSIS PAIN PSYCO-PHYSICAL TREATMENTS- ACCUPUNCTURE, MESSAGE, RELAXATION, TENS EXERCISE ANTI-OESTROGEN DRUGS LAPAROSCOPY/ OPEN SURGERY

22. LIMITATIONS OF DRUG THERAPY ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITE SHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASE RESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENT DOES NOT DEAL WITH ADHESIONS

23. META-ANALYSIS MIN/MILD ENDOMETRIOSIS PREG RATE nFOLLOW- UP NO TREAT 44% 235 0.5-3 DRUG THERAPY 41% 418 1- 5 SURGERY 65% 912 1 - 6 IVF 20 257