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ENDOMETRIOSIS

ESHRE Guidelines on Endometriosis 2013

Justin W. Ng Sinco

The following will be


presented:
Case Presentation
Endometriosis
Definition
Epidemiology
Etiology

Diagnosis
Treatment of Symptoms

Case
Presentation
E.L., 30 year-old Gravida 1 Para 1 (1001) who
came in with a chief complaint of hypogastric
pain.

E.L., 30 y.o.
Gravida 1 Para 1 (1001)
Born on July 28, 1984 in Manila
Living in Camarin, Caloocan
Works as a Telecommunication specialist
Married

History of Present
Illness
Menarche at 13 years old
Subsequent menses were regular
28 32 days interval

3 5 days duration
Moderate flow, 4 pads per day
(+) Dysmenorrhea

History of Present
Illness
5 years PTC
Severe cyclic hypogastric pain
Worsened after menstruation

Weakness and easy fatigability


No heavy bleeding, fever, dysuria, cough,
colds, headache

History of Present
Illness
5 years PTC
Consult at private OB

Endometriotic cyst, left ovary


Polycystic ovaries
Folic Acid 5mg OD
Vitamin B complex OD
OCP for 3 months

History of Present
Illness
3 years PTC
Danazol 200 mg 1 tab BID for 30 days (2012)
Injectable DMPA injected every three months
until November 2013

1 year PTC
Menstruation resumed regular cycle (May
2014)

History of Present
Illness

History of Present
Illness
5 days PTC
Transvaginal Ultrasound
Anteverted, normal-sized uterus with proliferative
endometrium (0.6 cm)
Right ovary is converted to a unilocular cyst with
low to medium level echoes measuring 3.2x2.5x2cm
Left ovary is converted to a unilocular cyst with
low to medium level echoes measuring 2.8x2.6x2cm
Cervix is unremarkable

Dx: G1P1 (1001); AUB secondary to Bilateral


Endometriotic Cysts

Past Medical History


Had mumps during childhood
Bronchial asthma: last attack 1995
1996
Non-hypertensive, non-diabetic
No known allergies to food and drugs
No history of prior hospitalization

Family History
Father, 58 years old, hypertensive and
with bronchial asthma
Mother, 66 years old, apparently well
Siblings: 2 siblings, with one sibling with
hypertension, high cholesterol, and
asthma
She denies other heredofamilial diseases
such as diabetes mellitus, malignancy,
liver, kidney and lung disease.

Personal & Social


History
Eldest among 3 siblings
Graduate with an Engineering degree
Works as a Telecommunications specialist
Married for 7 years to a 30 year-old
network engineer
Has a 7 year-old daughter
Non-smoker, non-alcoholic beverage
drinker

Gynecologic History
Menarche at 13 years old
Subsequent menses were regular
28 32 days interval

3 5 days duration
Moderate flow, 4 pads per day
(+) Dysmenorrhea, (+) Dyspareunia
(-) Post-coital bleeding, (-) Leukorrhea
Pap smear (2011) normal

Obstetrical History
Gravida 1 Para 1 (1001)
Delivered on 2007, term living girl, BW
3000g, appropriate for gestational age, via
NSD at Bernardino Hospital; no fetomaternal
complications

Method of
Contraception
OCP (2010 to 2013)
DMPA (2013)

Sexual History
Coitarche: 22 years old
1 sexual partner
Partner had 2 sexual partners

In a monogamous relationship

Review of Systems
Unremarkable

Physical Examination
General Survey: Patient is conscious,
coherent, not in cardiorespiratory distress,
with the following vital signs:
BP: 100/70 PR: 74 bpm
RR: 20 cpm
Temperature: 36.8 C
HEENT: Anicteric sclera, pink palpebral
conjunctivae, no nasoaural discharge, no
tonsillopharyngeal congestion, stye on right
lower lid
Neck: Supple neck, no neck vein
engorgement, no cervical lymphadenopathy

Physical Examination
Chest: Symmetrical chest expansion, no
retractions, no lagging
Lungs: Vesicular breath sounds, no
crackles, no wheezes.
Heart: Adynamic precordium, normal
rate, regular rhythm, no murmurs
Breast: Symmetrical contour, no
dimpling, no palpable mass, no
tenderness, no abnormal nipple discharge

Physical Examination
Abdomen: Flabby, soft, non-tender, normoactive
bowel sounds, no mass
Speculum exam: clean looking cervix with
minimal whitish discharge
Internal exam: normal looking external
genitalia, parous introitous, vagina admits two
fingers with ease, cervix firm and closed,
unenlarged uterus, no adnexal mass nor
tenderness
Extremities: No gross deformities, full and equal
pulses, no edema, no cyanosis
Skin: No active dermatoses

Dysmenorrhea
Primary

No pelvic pathology

Spasmodic

Secondary

With pelvic pathology

Congestive

Differential Diagnoses
Severe hypogastric pain
(Dysmenorrhea)

Endometriosis
Ectopic pregnancy
Pelvic Inflammatory Disease
Abortion

Endometriosis
Presence of endometrial-like tissue outside the
uterus, which induces a chronic, inflammatory
reaction (Kennedy, et al., 2005) ESHRE Guidelines
2013

Endometriosis
Chronic pain
Infertility
Diminished QOL

Prevalence:
2 10% of general female
population
Up to 50% in infertile women

Endometriosis, Etiology
Retrograde menstruation
Metaplastic conversion of coelomic
epithelium
Anatomic, Hematogenous or Lymphatic
dissemination
Immunologic dysfunction
Genetics

Metaplasia

Dissemination

Pathophysiolog
y

Ectopic endometrial tissue


Ovaries
Cul-de-sac
Bladder
Colon
Ureters

Diaphragm
Peritoneu
m
Posterior
fornix
Lungs

Progesterone
Estrogen

Cytokines
Prostaglandins
Neovascularization
Fibrosis
PAIN

INFERTILITY

Diagnosis
History
Physical Examination
Medical Technology

Signs & Symptoms


Gynecologic

Dysmenorrhea

Non-cyclical pelvic pain

Deep dyspareunia

Infertility

Fatigue in the presence of AOTA

Non-gynecologic

Dyschezia

Dysuria

Hematuria

Rectal bleeding

Shoulder pain

Physical Examination
Speculum examination
Bimanual palpation
Rectovaginal palpation
Abdomen & Pelvis

Physical Examination
Induration and/or
nodules of the
rectovaginal wall,
or visible vaginal
nodules in the
posterior vaginal
fornix : Deep
endometriosis

Physical Examination
Adnexal mass: Ovarian endometrioma
Normal clinical examination does not rule
out disease

Medical Technology
Laparoscopy with histopathology:
Gold standard
Histology (Ovarian
endometrioma/Deep
infilitrating disease)
to rule-out
malignancy

Laparoscopy
Transvaginal ultrasonography
3D sonography
MRI
Biomarkers

Transvaginal ultrasound
Ground glass echogenicity and 1 to 4
compartments and no papillary structures
with detectable blood flow
Ovarian
Endometrioma

From http://www.ultrasound-images.com/

Transvaginal
ultrasound, E.L.
Right ovary is converted to a unilocular
cyst with low to medium level echoes
measuring 3.2x2.5x2cm
Left ovary is converted to a unilocular
cyst with low to medium level echoes
measuring 2.8x2.6x2cm

Additional Imaging
If with suspicion of deep endometriosis:
Bowel : Barium enema, Transvaginal or
Transrectal UTZ
Bladder : Transvaginal UTZ with full
bladder, Cystoscopy
Ureter : MRI, CT Urogram
Sensitive > Specific

Treatment Goals
Relief of pain
Fertility, if wanted

Admitting
Diagnosis
Gravida 1 Para 1 (1001)
Secondary dysmenorrhea probably secondary to
bilateral endometriotic cysts

Pain Management
Counselling plus
Analgesics
Combined hormonal contraceptives
Progestagens
Surgery

Hormonal Therapies
Hormonal
contraceptives
Progestagens
Anti-progestogens
GnRH agonist

Patient preference
Side effects
Efficacy
Cost
Availability

Hormonal
Contraceptives
Dyspareunia
Dysmenorrhea
Non-menstrual pain
Chronic pelvic pain

Combined hormonal
contraceptive
Combined oral
contraceptive pills
Vaginal contraceptive
ring or Transdermal
patch

Progestagens & Antiprogestagens


Medroxyprogesterone acetate (oral or
depot)
Dienogest
Cyproterone acetate
Norethisterone acetate
Danazol
LNG-IUS
Gestrinone

GnRH agonists
Nafarelin
Leuprolide
Buserelin
Goserelin
Triptorelin

Hormonal
add-back
therapy

Caution in young & adolescent women

Aromatase Inhibitors
For rectovaginal endometriosis refractory
to other medical or surgical treatment

Aromatase
Inhibitor

OCP

Progestagen
GnRH agonist

Analgesics
NSAIDs or other analgesics may be given
Discuss risks
Gastric ulceration
Inhibition of ovulation
Cardiovascular disease

Surgery
1. Operative laparoscopy
Ablation vs. Excision
Equal effectiveness

2. Interruption of Pelvic Nerve Pathways


Laparoscopic Uterosacral Nerve Ablation
(LUNA)
Presacral Neurectomy

3. Ovarian endometrioma
Cystectomy vs. Drainage & Coagulation
CO2 Laser Vaporization

Surgery
4. Deep Endometriosis
Surgical removal
Referral to centre of expertise

5. Hysterectomy
Hysterectomy + oophorectomy + removal of
endometrial lesions
Women with completed family; failed to
respond to conservative treatments

6. Adhesion Prevention
Oxidized regenerated cellulose
Other anti-adhesion agents

Pre-operative hormonal
treatment
Alleviates symptoms before the surgery
No change in outcome of surgery

Post-operative
hormonal treatment
Short-term vs. Long-term
Long-term therapy
Secondary prevention:
Prevent recurrence of pain symptoms
Prevent recurrence of disease

LNG-IUS or Combined hormonal


contraceptive for at least 18 24 months

Extragenital
Endometriosis
Surgical removal
Medical treatment

Non-medical strategies
Supplements and alternative medicine
are not recommended.

Plan
Patient is for Laparoscopic bilateral
oophorocystectomy with chromopertubation

Plan
For Laparoscopic bilateral
oophorocystectomy with
chromopertubation
NPO 6 hours prior to OR
IVF once on NPO: 1L D5LR for 8 hours
For Blood typing
Give Cefuroxime 1.5 g TIV (-) ANST 1
hour prior to OR

Course in the Ward


2nd Hospital Day: Patient underwent
Laparoscopy, surgical with bilateral
partial oophorectomy,
chromopertubation and
electrofulguration of endometriotic
implants
Patient was discharged improved on the
4th hospital day.

Laboratory Results
Blood type: A+
Histopathologic report of the bilateral
ovarian cysts: results pending

Laboratory Results
CBC

Hgb 150
Hct 0.43
Platelet count 351
WBC 9.5 (0.65,0.23,0.67,0.04)

Urinalysis
Yellow/Hazy/6.0/1.015/Neg/Neg/1-2/0-2

Laboratory Results
FBS 5.8
BUN 3.85
Crea 64.7
SGPT 19.7
SGOT 13.8
Na 139
K 4.4
Ca 1.10

Laboratory Results
CXR: Normal
ECG: Sinus rhythm

Operation Technique
Ovarian epithelium covering the cysts
were excised; edges of the cyst were
stripped from the normal ovarian tissue.

Intra-operative findings
No ascites. Liver, spleen, subdiaphragmatic
surface and bowel were smooth
Uterine corpus was retroverted with smooth,
pinkish serosa. Posterior cul-de-sac has
multiple endometriotic implants.
Left ovary was cystically enlarged to 5x5cm
with a unilocular cyst measuring 3x2cm
exuding chocolate-brown fluid
Right ovary was likewise enlarged to 4x3cm
with a 1 cm cystic mass exuding
chocolate-brown fluid

Intra-operative findings
Both fallopian tubes were grossly normal
with egress of methylene blue on
chromopertubation. The rest of the
abdomino-pelvic organs are grossly
normal

Post-operative
Diagnosis
Gravida 1 Para 1 (1001)
Pelvic endometriosis AFS Stage III with bilateral
endometrioma

Treatment of Infertility
Medical
Surgical
Medical adjunct to surgery
Alternative treatments

Hormonal therapy
Not effective

Adjunct Hormonal therapy


Not recommended

Surgery
Operative laparoscopy + adhesiolysis
CO2 Laser vaporization vs. Monopolar
electrocoagulation
Excision of endometrioma capsule
Counselling

Non-medical strategies
Supplements and alternative medicine
are not recommended.

Assisted reproduction
Intrauterine insemination with controlled
ovarian stimulation within 6 months after
surgical treatment
Assisted reproductive technology
(IVS/ICSI) is recommended
GnRH agonist for 3 to 6 months prior

Menopause &
Endometriosis
Estrogen/Progestagen therapy or
Tibolone reduces menopausal symptoms
in surgically-induced menopause
Given at least up to the age of natural
menopause

Asymptomatic
Endometriosis
Incidental findings of ectopic foci with no
pelvic pain or infertility.
Surgical excision and ablation are not
recommended

Prevention of
Endometriosis
Etiology is unknown, thus primary
prevention is uncertain
Oral contraceptives : uncertain
Exercise : uncertain