Endometriosis PDF

ENDOMETRIOSIS The presence of a tissue similar to normal endometrium in structure and function outside the lining of the uterine cavity. Endom.interna Adenomyosis Endom.externa True endom.  ADENOMYOSIS Aetiology: -- Repeated Pregnancies. - Vigorous Curettage. - - Hormonal...

ENDOMETRIOSIS The presence of a tissue similar to normal endometrium in structure and function outside the lining of the uterine cavity. Endom.interna Adenomyosis Endom.externa True endom.  ADENOMYOSIS Aetiology: -- Repeated Pregnancies. - Vigorous Curettage. - - Hormonal Imbalance. -  Adenomyosis---Pathology Symmetrical enlargement of uterus. Localized or diffuse. Histology: -Glands +Stroma surrounded by muscle fibres. Adenomyosis--Clinical features End of reproductive life. Multiparous. Asymptomatic. Menorrhagia:-Enlarg. of uterus. - Blood supply. -Impaired contractility. -Ass.endom.hyperplas. Dysmenorrhea &Dyspareunia.  Adenomyosis-----cont. Myoma vs Adenomyosis -Rarely enlarg.uterus >12- 14wks. -Regular enlarg.of the uterus. Treatment TAH  ENDOMETRIOSIS Implantation Theory(sampson) Coelomic Metaplasia. Lymphatic&Vascular Dissemin. Endometriosis--Predisp.factors Age 4th decade. Reprod.history C delay 1st pregn. High Social class. Genetic 7% of 1st degree relat. 1% of unrelated control Auto-immune.  Endometriosis---Increase Better ability to recognise the disease. The growing number of laparoscopic procedure. Emergence of predisposing factors. Patients and physicians----more aware of the disease.  Endometriosis---Pathology Macroscopic: -Small black dots(powder burn) - - - Large cystic masses(choclate cysts) - Others black, dark brown, bluish puckered lesions, nodules. - Atypical lesions: -Red implants( petechial, vesicular, polypoid, red flame like) - Serous or clear vesicles. - White plaques and scaring.  Endometriosis--Pathology Microscopic -Endometrial glands. - - Stroma. - - Evidence of bleeding. - endometrial sandstroma - Med Endom.---Clinical presentation 4 I delay -gentic Asymptomatic - 25% ish solic - class ⑧ Pain -The 1-2 commonest ↑ 3 -Pelvic pain,Dysm,Dysp. # Menorrhagia - Infertility - Acute - abdomen Intermittent pyrexia - Endometriosis--presentation Suggestive of endom: - Pelvic tenderness - Fixed retroverted uterus. - Tender uterosacral ligament. - Enlarged ovaries. DeeplyC infiltrating nodules---most reliably detected when clinical exam performed during menstruation.  Endometriosis--Diagnosis Symptomatology. Defenitive Diagnosis: Laparoscopy Histology  Endometriosis--Diagnosis - Laparoscopy: -Gold standard investigation. I - - Specific time in the menstrual cycle ----Insufficient evidence. - Classification systems----subjective & correlate poorly with pain symptoms  Endometriosis---Histology Is it necessary----controversial. Positive histology-----confirm. Negative histology----doesn t exclude. Histological confirmation of at least one lesion is ideal. Endometriomas > 3 cm and deep infiltrating disease----Histology.  CA 125 May be elevated. Compared with laparoscopy----has no value as a diagnostic tool.  Endometriosis &Infertility 15% of infertile women Endom. 40-60% of endom. Infertility Mechanisms: -Adhesions -Dyspareunia - prostaglandinsC -Tubal motility I -Folliculogen. -C.L function - Macrophages -LUF - prolactine  Endometriosis--Treatment Depends on: Severity of symp. - Prev.Rx. 0 Age Fertility 3 expectation. Types: Expectant Surgical Medical Endometriosis---Medical Rx Endom.goes into remission during pregnancy E Pseudopregnancy3 https://drive.google.com/drive/fo Endom.invariably disappears after lders/1P06cie0cAvRCWUQTW1 - ySHm7NhtZOv-jO menopause - SPseudomenopause5 Androgen causes regression of endometriosis Androgen  Endometriosis--Medical Rx Combined pills. Progestogen. Testosterone. - Danazol. - Gestrinone. - GnRh agonists Aromatase inhibitors  I DANAZOL Isoxazole derivative of 17-alpha- ethinyltestosterone. Action: -Bind to SHBG Free testost. - Synthesis of SHBG by the liver -Prevent medcyclic surge of FSH,LH -Inhibits several enzym. processes involved in ovarian steroidogenesis Estrogen & Androgen X Danazol---Side Effects Weight gain. Oily skin Fluid retention. Atrophic vagin. Breast size. Muscle cramps. Growth of facial Irrever.deepen. hair. of voice. Emotion.lability Choles. HDL Fatigue. Insuline resist.  & DANAZOL----cont. Rx for 6-9 months. Dose 200mg twice daily. Contraindications: -Pregnancy -Breast feeding -Severe hepatic,cardiac,renal dis. -Thromboembolism -Porphyria -Androgen dependent tumours  Medical Rx----cont. X Gesrinone:(Trienic-19-Norsteroid) -Inhibits midcyclic surge of FSH,LH -Same side effects as danazol. -Long 1/2 life(2.5-5mg twice weekly) GnRh agonists: -Menopausal symptoms. -Breakthrough bleeding. -Loss of bone Ca.  Medical Treatment---cont Aromatase Inhibitors:(anastrozole,letrozole) -Aromatase enzyme that - catalyzes the final and the key step of estrogen production. - Decrease both peripheral and local estradiol production. - May be better at suppressing local estrogen formation in endometriotic tissues than GnRH -----More effective. - Combined with ovarian suppression.  Endometriosis--Surgical Rx - Radical: TAH+Removal of as much endom. total and hostedonein r ae tissue as possible+Bilat.oophorect. - Conservative: -Division of > adhesions,Tuboplasty--- -Presacral neuroectomy -Laser uterine nerve ablation  Medical treatment of endom associated pain. Empirical treatment without definitive diagnosis----Appropriate. -Adequate analgesia. ↳- Progestogens 3 ↳- Combined oral contraceptives.S  Medical RX---cont - Effectiveness of NSAIDS----inconclusive evidence. Suppression of ovarian function for 6 L months----reduce pain.I Symptom recurrence is common following medical treatment. Aromatase inhibitor---may be effective. - LNG-IUS-----reduce pain Surgical Rx of Endom-associated pain Ideal practice diagnose and remove surgically. Ablation----reduce pain. LUNA-----Doesn t reduce pain. Can be reduced by removing the entire lesions in severe and deeply infiltrating disease. Preop & postop hormonal rx----insuficient evidence of benefit.  Treatment of Endom-associated Infertility Medical treatment: -Minimal-mild disease----Not effective and shouldn t be offered. -More severe disease---No evidence of effectiveness. ↳ Ablation & adhesiolysis----effective in minimal- -mild disease. The role of surgery in improving pregnancy rate for moderate-severe disease is uncertain. Postop hormonal rx ---no beneficial effect.  Assisted Reproduction in Endometriosis IUI in minimal- mild---- Improves fertility. O IVF is appropriate treatment: -Tubal function is compromised - - Male factor - Other treatment have failed -- GnRH agonists for 3-6-> months before IVF--- increase rate of clinical pregnancy - Thank you