1. Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn

2.  Definition: Ectopic Endometrial Tissue  True Incidence Unknown: ? 1-5%  Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

4.  Asymptomatic.  Pain (DYS…….): - Dysmenorrhea (crescendo = progessive) - Dyspareunia. - Dyschesia. - Dysuria.  Chronic Pelvic Pain  Backache.  Acute abdomen.  Premenst. Tension syndrome.  Abnormal Uterine Bleeding  Infertility  Pelvic Mass (Endometrioma)  Misc: Tenesmus, Hematuria, Hemoptysis

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

7. < 19 6% 19 – 25 24% 26 –35 52% 36 –45 15% > 45 3%

8.  Sampson: “Retrograde Menstruation”  Hematologic Spread  Lymphatic Spread  Coelomic Metaplasia  Genetic Factors  Immune Factors  Combination of the Above No Single Theory Explains All Cases of Endometriosis

9.  History (The most important)  Symptoms  Physical Examination (not much help)  Serum Markers (Lacks sensitivity)  Ultrasound (of little value except endometrioma)  Magnetic Resonance Imaging (MRI) (a good guess!)  Other Imaging Modalities ◦ immunoscintigraphy and positron emission tomography  Transvaginal Hydrolaparoscopy  Laparoscopic Visualization of the Pelvis (The gold standard) ◦ Biopsy Preferable Over Visual Inspection  Novel Diagnostic Test Rule out other Causes of Symptoms (The next most important)

10.  Laparoscopy (“Gold Standard)  Laparotomy  Inconclusive: CA-125, CA-199Pelvic Exam, History, Imaging Studies  Biopsy Preferable Over Visual Inspection

11. Endometriosis May Appear  Brown  Black (“Powderburn”)  Clear (“Atypical”) Endometriosis May Be Associated with Peritoneal Windows

12. Variety of endometriotic lesions seen at laparoscopy

14. 0varian endometriosis ENDOMETRIOSIS AND ADOLESCENCE

15.  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.

17.  Stage I (minimal) 1 – 5  Stage II (mild) 6 – 15  Stage III (moderate) 16 – 40  Stage IV (severe) > 40

18. Endometriozis-Evreleme EVRE-1 (minimal= 1-5) EVRE-2 (hafif = 6-15) EVRE-3 (orta = 16-40) EVRE-4 (ağır = > 40)

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

20.  NSAIDs  OCPs (Continuous)  Progestins  Danazol  GnRH-a  GnRH-a + Add-Back Therapy  Misc: Opoids, TCAs, SSRIs

21.  “Pseudopregnancy” (Kistner)  ? Minimizes Retrograde Menstruation  Lower Fertility Rates than Other Medical Treatments  Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects

22.  May be as Effective as GnRH-a for Pain Control  MPA 10-30 mg/day, DP 150 mg Semi- Monthly  May be Taken Long-Term  Relatively Inexpensive  Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea

23.  Weak Androgen  Suppresses LH / FSH  Causes Endometrial Regression, Atrophy  Expensive  Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes

24.  Initially Stimulate FSH / LH Release  Down-Regulates GnRH Receptors– ”Pseudomenopause”  Long-Term Success Varies  Expensive  Use Limited by Hypoestrogenic Effects  May be Combined with Add-Back (? >1 Year )

25.  Excision Yes / Fulgeration No!  Resection of Endometrioma  Lysis of Adhesions, Cul-de-sac Reconstruction  Uterosacral Nerve Ablation  Presacral Neurectomy  Appendectomy  Uterine Suspension (? Efficacy)  Hysterectomy +/- BSO