Management of endometriosis

Associate Professor Dr. Anisah Jalaluddin

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction.

Which symptoms are typically associated with endometriosis?

severe dysmenorrhoea deep dyspareunia chronic pelvic pain ovulation pain cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain infertility chronic fatigue dyschezia (pain on defaecation).

Sign
Deeply infiltrating nodules are most reliably detected when clinical
examination is performed during menstruation.

Pelvic tenderness Fixed, retroverted uterus Tender uterosacral ligaments or Enlarged ovaries

Physical sign

What is the gold standard diagnostic test?

Visual inspection of the pelvis at laparoscopy

diagnostic laparoscopy is associated with an approximately 3% risk of minor

complications, such as nausea or shoulder tip pain, and

a risk of major complications, such as bowel perforation, vascular damage,

of between 0.6/1000 and 1.8/1000

should not be performed during or within 3 months of hormonal treatment,

to avoid under-diagnosis

Appearance: blackened spot, red implants, vesicles. Peritoneal defects and

endometriomas.

Variety of endometriotic lesions seen at laparoscopy

Prof.Onetto Santiago. Chile/2001

Surgically, endometriosis can be staged IIV (Revised Classification of the American Society of Reproductive Medicine).[42] but it is important to note staging assesses physical disease only, not the level of pain or infertility. A patient with Stage I endometriosis may have little disease and severe pain, while a patient with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings:

Stage I (Minimal) Findings restricted to only superficial lesions and possibly a few filmy adhesions Stage II (Mild) In addition, some deep lesions are present in the cul-de-sac Stage III (Moderate) As above, plus presence of endometriomas on the ovary and more adhesions. Stage IV (Severe) As above, plus large endometriomas, extensive adhesions. Endometrioma on the ovary of any significant size (Approx. 2 cm +) must be removed surgically because hormonal treatment alone will not remove the full endometrioma cyst, which can progress to acute pain from the rupturing of the cyst and internal bleeding.

How reliable is imaging for diagnostic purposes?

transvaginal ultrasound (TVS) has limited value in diagnosing peritoneal
endometriosis but it is a useful tool both to make and to exclude the diagnosis of an ovarian

there is insufficient evidence to indicate that magnetic resonance imaging

(MRI) is a useful test to diagnose or exclude endometriosis compared to laparoscopy.

MRI

Ultrasound

How reliable is serum CA125 measurement for diagnostic purposes?

Serum CA125 levels may be elevated in endometriosis. However,
compared with laparoscopy, measuring serum CA125 levels has no value as a diagnostic tool.

The estimated sensitivity was only 28% for a specificity of 90%.

Treatment of Endometriosis
Management of pain

Surgery Medical therapy

Treatment of infertility
Surgery Ovulation induction

Assisted reproductive technology

Medical treatment of endometriosisassociated pain

Treatment of Pain
Medical management
Oral contraceptives, progesterone, danazol GnRH agonist with add-back Alternating GnRH agonist and OCs Aromatase inhibitors - letrozole

NSAID

CHOICES OF MEDICAL THERAPY

Drug group Example Side effects

1 Progestogens

Medroxyprogesterone Duphaston Norculot

Danocrine

Mood swing Nausea bloatedness

Hoarseness Hirsuitism, acne Weight gain, bloatedness Vasomotor symptoms/ osteoporosis

2 Danazol

(synthetic androgen)

3 Oral contraceptives Any OCPs 4 GnRH analogue

Zoladex (Goserelin) Lucrin

 COCPs act by ovarian suppression. Initially, a trial of continuous or cyclic

COCPs should be administered for 3 months.

All progestational agents act by decidualization and atrophy of the

endometrium.

GnRH analogues produce a hypogonadotrophic-hypogonadic state by

downregulation of the pituitary gland.

Duphaston - 10mg bd or tds - from day 5 to day 25 cycle Or Continuously for 6 9 months

Danazol acts by inhibiting the midcycle follicle-stimulating hormone (FSH)

and luteinizing hormone (LH) surges and preventing steroidogenesis in the corpus luteum. It is the most extensively studied agent for endometriosis.

Goserelin and leuprolide acetate are the commonly used agonists.

The recommended dose is 600-800 mg/d

Empirical treatment of pain symptoms without a definitive diagnosis

Therapeutic trial of a hormonal drug to reduce menstrual flow is
appropriate.

It include counselling, adequate analgesia, progestogens or the combined

oral contraceptive. It is unclear whether the combined oral contraceptives should be taken conventionally, continuously or in a tricycle regimen.

A gonadotrophin-releasing hormone (GnRH) agonist may be taken but this

class of drug is more expensive and associated with more adverse effects and concerns about bone density.

How effectively do nonsteroidal anti-inflammatory drugs (NSAIDs) treat endometriosis-associated pain?

Is there a role for the levonorgestrel intrauterine system (LNG-IUS)?

There is inconclusive evidence to

show whether NSAIDs (specifically naproxen) are effective in managing the pain.

The LNG-IUS appears to reduce

endometriosis-associated pain.

Surgical treatment of endometriosisassociated pain

Management of Pain
Surgical treatment
Ablation of endometrial implants Lysis of adhesions Ablation of uterosacral nerves Resection of endometriomas

Combined surgical and medical treatment

Surgical care can be broadly classified as

conservative when reproductive potential is retained semiconservative when reproductive ability is eliminated but ovarian
function is retained

radical when the uterus and ovaries are removed. Age, desire for future
childbearing, and deterioration of quality of life are the main considerations when deciding on the extent of surgery.

How should ovarian endometriomas be managed?

Laparoscopic cystectomy for ovarian endometriomas is better than
drainage and coagulation.

The recurrence of endometriomas and symptoms are reduced by excisional

surgery more so than drainage and ablation.

Is there a role for hormonal treatment after surgery? Postoperative hormonal treatment has no beneficial effect on pregnancy
rates after surgery.

Compared with surgery alone or surgery plus placebo, postoperative

hormonal treatment has no effect on pregnancy rates.

Endometrioma

Dissection of an Endometrioma
Ovary Incision Tube

Removal

Result

When should surgical treatment be considered?

Ideal practice is to diagnose and remove endometriosis surgically.
Does surgical treatment relieve pain?

Ablation of endometriotic lesions reduces endometriosisassociated pain compared with diagnostic laparoscopy.
Does nerve ablation provide pain relief?

itself does not reduce endometriosis-associated pain. presacral neurectomy,especially in severe dysmenorrhoea, although
the evidence is inconclusive.44

What is the role of more radical surgery?

Endometriosis associated pain can be reduced by removing the entire
lesions in severe and deeply infiltrating disease.

If a hysterectomy is performed, all visible endometriotic tissue should be

removed at the same time.

Bilateral salpingo-oophorectomy may result in improved pain relief and a

reduced chance of future surgery.

Is there a role for surgical treatment of endometriomas before IVF?

Laparoscopic ovarian cystectomy is recommended for endometriomas
4 cm in diameter.

to confirm the diagnosis histologically; reduce the risk of infection; improve access to follicles, and possibly improve ovarian response and prevent endometriosis progression

The woman should be counselled regarding the risks of reduced ovarian function after surgery and the loss of the ovary.The decision should be reconsidered if she has had previous ovarian surgery.

The role of complementary therapies in relieving endometriosis-associated pain is unclear.

Many women with endometriosis report that nutritional and
complementary therapies such as homeopathy, reflexology, traditional Chinese medicine or herbal treatments, do improve pain symptoms.

While there is no evidence from randomised controlled trials in

endometriosis to support these treatments, they should not be ruled out if the woman feels that they could be beneficial to her overall pain management and/or quality of life, or work in conjunction with more traditional therapies.

Long term management

Endometriosis is progressive and can result in chronic pain and infertility.

Gynecologic follow-up is advised.

Benefits of Duphaston

30

Case

A 37 year-old nulliparous lady, married for the last 7 years, complains of

severe dysmenorrhoea of 10 years. She is also very anxious to conceive. Examination revealed a tender left iliac fossa with a tender mass which has restricted mobility. Pelvic examination confirms a retroverted uterus with mobility and a tender mass in the left iliac fossa.

Key points
Endometriosis is a common disease affecting women of the reproductive
age group (10%). It may begin in late adolescence. Symptom dysmenorrhoea and infertility.

Pelvic endometriosis causes scarring, fibrosis and adhesions. There is a role of medical management in mild stage of endometriosis The surgical intervention is indicated in moderate to severe endometriosis

Thank you