1. ENDOMETRIOSIS Akmal Abbasi

2. DEFINITION The presence of functional endometrial tissue outside the uterine cavity.

3. EPIDEMIOLOGY  Affects 5-20% of all women of childbearing age.  Mean age of diagnosis 25-29yrs  No racial difference in prevalence.

4. Sites Pelvic Extra pelvic Umbilicus. Scars (Lap.). Lungs & plura. Others.

5. Pelvic Endometriosis Uterine= Adenomyosis (50%). Extraut: - Ovary 30% - Pelvic peritoneum 10%. - F. tube. - Vagina. -Bladder & rectum. - Pelvic colon. - Ligaments.

10. ETIOLOGY Three main theories of pathogenesis Retrograde transport of endometrial tissue through the fallopian tubes at menstruation leading to seed of the peritoneal cavity.

11. ETIOLOGY Metaplastic transformation of coelomic epithelium leading to functioning endometrial tissue extra pelvic sites.

12. ETIOLOGY Spread of endometrial tissue through lymphatic and vascular channels. Possibility of autoimmune cause. Possible role of toxic chemical exposure.

13. SYMPTOMS  Dysmenorrhea.  Dyspareunia.  Infertility.  Menstrual irregularities.  Chronic pelvic pain.

14. Age at Diagnosis < 19 6% 19 – 25 24% 26 –35 52% 36 –45 15% > 45 3%

15. CLINICAL FINDINGS  Normal Physical exam even with moderate to severe endometriosis.  Fixed retroversion of uterus.  Rectovaginal exam Uteroscral or rectovaginal septum nodularity

16. CLINICAL FINDINGS  Pelvic exam (premenstrual ) Fixed uterine retroversion. CMT. Adenexal tenderness. Adenexal masses- endometrioma (Chocolate cyst) of the ovary- (15cm)

17. DIFFERENTIAL DIAGNOSIS  Chronic PID.  Pelvic adhesions from PID  Prior surgery.  Ovarian cysts.  Ovarian tumors.

18. LAB EVALUATION  CA 125 Found repeatedly in patients. Not recommended for screening.  GC and chlamydia.  CBC  Urinalysis.

19. DIAGNOSTIC EVALUTIOAN  Ultrasound Identification of cysts. Cannot detect focal implants.  MRI Sensitivity and specificity very low.

20. DIAGNOSTIC EVALUTIOAN  Visualization by Laparoscopy or laparotomy considered the gold standard of for diagnosis.

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

22. Classification / Staging Several Proposed Schemes Revised AFS System: Most Often Used Ranges from Stage I (Minimal) to Stage IV (Severe) Staging Involves Location and Depth of Disease, Extent of Adhesions

23. TREATMENT Optimal treatment regimen depends on  Desired pain relief.  Desired fertility.

24. TREATMENT Surgery Conservative  Preserve reproductive organs  Use of laser or thermal cautery.  Adhesiolysis via laporoscopy or laparatomy.  1/3 of patients have a recurrence.

26. TREATMENT Surgery  Radical ( definitive procedure ) Hysterectomy with salpingo- oophorectomy. 90% of patients pain free. Not for women desiring pregnancy.

27. TREATMENT Drugs of choice  Danazol (Danocrine).  GnRH agonists  Progesterons

28. TREATMENT  Danazol (Danocrine).  Derivative of 17  -ethinyl testosterone.  400mg – 800mg b.i.d to q.I.d.  Creates high androgen,low estrogen state with anovulation and amenorrhea, inhibits the the growth of endometrial tissue.  6mths or 2wks if as adjunct therapy.

29. TREATMENT  GnRH agonists (creates hypoestrogenic state)  Usually 6mth duration of treatment)  Nafarelin acetate (Synarel) 0.2 – 0.4mg intranasally b.i.d.  Leuprolide acetate ( Luprom) 3.75mg IM monthly (depot). 0.5 – 1.0mg SQ daily.

30. TREATMENT  Progesterons ( causes atrophy of endometium )  Depo-Provera 100mg q2wks PO for 4 doses. Then 200mg monthly for 4 mths.  Medroxyprogesterone acetate (MPA) 30mg PO Daily for 3 mths. Depot may cause prolonged anovulation.

31. TREATMENT ALTERNATIVE DRUGS  Combined estrogen –progesterone OCs with 30 to 35  g ethinyl estradiol to produce amenorrhea. Less effective than other meds. Use if other drugs are contraindicated.

32. TREATMENT  NSAIDs may be effective for pain relief

33. Patient education  Avoid delaying childbirth once diagnnosis is made.