?

Patofisiologi

Implant Endometrioma Rectovaginal Others

ENDOMETRIOSIS MANY QUESTION?

E N D O M E T R I O S I S

S Y M P T O M S

?
ELIMINATED DIAG NOSIS TREAT MENT GOAL EVALU ATION WHEN HOW

SYMPTOM
Clinical sign Laboratory Imaging Laparoscopy

Clinical sign Laboratory Imaging Laparoscopy

Medical : What & how Surgical : ablation Excision, Resection -Laparoscopy -Laparotomy Surgical + medical IVF (infertility)

Infertility Tumor Pain Combined Others

FAIL ?

Next Treatment

DIAGNOSIS ENDOMETRIOSIS
1. ANAMNESA
2. Klinik. 3. Laboratorik. 4. Trans Vaginal Sonography (TVS). 5. Laparoskopi.

NYERI
- CHRONIC PELVIC PAIN - DYSMENORRHEA - INTERMENSTRUAL PAIN - DYSPAREUNIA

PHYSICAL EXAMINATION
TYPICALLY NORMAL
KADANG-KADANG
- Plaque pada fornix posterior - ??? Pada recto vaginal - Uterus fixation - Focal tenderness / ??? - Uterosacral ligaments

DIAGNOSA LABORATORIK
CA 125 CELL SURFACE ANTIGEN

ADVANCE ENDOMETRIOSIS

CA 125
SENSITIVITY ( + 50%) SPESIFICITY ( + 90%)
SCREENING TEST IS NOT TOO EFECTIVE

TVS
USEFUL FOR DETECTION OF

OVARIAN ENDOMETRIOSIS
NOT FOR PELVIC ADHESIONS OR SUPERFICIAL PERITONEAL PLAQUE

CLINICAL SYMPTOMS OF ENDOMETRIOSIS

PAIN TUMOR INFERTILITY

TREATMENT OF ENDOMETRIOSIS

SYMPTOMATIC

PAIN

TUMOR & INFERTILITY

DIAGNOSIS SYMPTOM & TVS

DIAGNOSIS LAPAROSCOPY

TREATMENT Medical : - NSID - OC - GnRHa Surgery

DIAGNOSIS Adhesion Tube Other

TREATMENT Lysis Excision Reconstruction

ENDOMETRIOSIS AND PAIN

MEDICAL THERAPY : COMPARATIVE TRIALS

DANAZOL vs GnRH agonist 15 trial No difference in pain relief PROGESTINS vs GnRH agonist 3 trials No difference in pain relief OC vs GnRH agonist 1 trial OC have less relief of dysmenorrhea and dispareunia

CHRONIC PELVIC PAIN FLOW CHART

Abnormal

History, physical examination

Normal Response

Specific therapy

Empiric NSAIDs, OCs

No response Response

Continue therapy

Empiric GnRH agonist No response Laparoscopy, consultation, pain clinic

Continue therapy To total 6 months

SURGICAL THERAPY

SURGICAL TREATMENT OF ENDOMETRIOSIS

Restore Anatomical distortion (abnormality)

Reduce of Visible endometriosis Tissue

Minimal Recurrency rate Optimal result

Surgical Adhesiolysis Restoration of Normal anatomy

Radical

Conservative

BSO & TAH

Ablation Excision Removal (endometrioma) Resection

RCT EXCISION vs DIAGNOSTIC LAPAROSCOPY

39 women randomized to excision or diagnostic laparoscopy Improvement at 6 month : Diagnostic laparoscopy Excision of endometriosis
Abbot JA et al, JAAGL 2002 ; 9 : S1

22 % 73 %

SURGICAL TREATMENT
2 year pain recurrence Excision (178 ) Ablation ( 39 ) 42 % 77 %

Winkel & Bray, ASRM 1996

SURGERY OR MEDICAL THERAPY : 6 MONTHS POST TREATMENT Pain relief : Telimaa (MPA) Telimaa (Danazol) Sutton (Surgery) 50 % 74 % 47 %

ACOG PRACTICE BULLETIN

Clinical Management Guideline for Obstetrician Gynecologist Number 11, December 1999

Medical management of endometriosis

Therapy with a GnRH agonist is an appropriate approach to the management of the women with chronic pelvic pain, even the absence of surgical confirmation of endometriosis, provide that a detail initial evaluation fails to demonstrate some other cause of pelvic pain

ENDOMETRIOSIS & INFERTILITY

DIAGNOSIS

TREATMENT

EVALUATION

GOAL

Clinical Sympt.

Lap. Dx

Surgery ( Lap )

Medical

Symptoms & Time

Cure ? Symptom Pregnancy Tumor

Dx

Tx

Endometriosis Adhesion Tube Etc

Lysis Excision Ablation Reconstruction

TREATMENT OF ENDOMETRIOSIS & INFERTILITY

Peritoneal

Ovarial

Rectovaginal
Lysis Excision Resection Drainage Ablation

Ablation Excision

Drainage

Adhesiolysis Excision
Laser (evaporation Thermal L (electrical)

Removal (cystectomy)

OVARIAN ENDOMETRIOSIS & INFERTILITY ( ENDOMETRIOMA )

Malignant

0,7 1,0 %

15 20 % Surgical & Medical

4%

Atipy

OR
Drainage & Ablation 23,5 % 18,8 % Drainage
Cumulative Pregnancy rate ( 24 months )
Recurency rate

Removal (cystectomy) 66,7 % 6,2 %

Maoris Panos and Brett Lincoln : Endometriotic Ovarian Cyst, the Case for Excisioned laparoscopic Surgery, Gynaecological Endoscopy, 2002, 11: 231-4