The Modern Management of Endometriosis

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The Modern Management of Endometriosis

• Malcolm Padwick

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What is it ?

• The presence of endometrial tissue outside of the
  uterine cavity
• cul-de-sac
• rectovaginal septum
• surface of rectum
• fallopian tubes and ovaries
• uterosacral ligaments
• bladder
• pelvic side wall

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Is it inherited?

• 6 to 8 fold increase risk in sisters compared to
  unrelated women
• affected sisters are more likely to have severe
  disease
• OXEGENE study ongoing
• ovarian cancer link
• racial

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Aetiology

• Retrograde menstruation
• tissue transplantation
• peritoneal cell metaplasia
• venous spread
• lymphatic spread
• immune failure

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Incidence

• At sterilisation 2 to 5 have endometriosis
• 25 to 50 of women investigated for infertility
• estimated 5 million women in USA
• 6 to 7 of all females

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Endometriosis symptoms

• dysmenorrhoea
• pelvic pain
• infertility
• dyspareunia
• menstrual irregularities
• other cyclic bleeding

• 70
• 40
• 35
• 33
• 15
• 1-2

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Endometriosis

• Diagnosis
• laparoscopy

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The natural progression

• Lesions
• Clear mean age 21.5
• Red
• Black mean age 31.9
• disease is progressive in 47 - 64 of women and
  in 20 of treated women (Redwine)

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Endometriosis and Fertility

• 30 to 40 of women with endometriosis are
  infertile
• may be obvious anatomical abnormalities
• hormonal E2 reduced LH blunted
• multicystic ovaries
• Luteinized Unruptured Follicle X 3
• peritoneal fluid, macrophages, cytokines,
  interferon C3, C4 are all increased
• plasma embryotoxic in 78 of cases

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Endometriosis

• Management options 1
• Diagnostic laparoscopy
• Drugs
• OCP
• Provera
• Danazol / Gestrinone
• GNRH analogues
• Surgery
• Hysterectomy with BSO

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Endometriosis and Fertility

• Hormonal or antihormonal therapy has no
  beneficial effect
• on fertility either alone or as an adjunct to
  surgery ( RCOG recommendation)
• only surgical ablation or excision of disease
  will restore fertility ( RCOG recommendation)

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Endometriosis

• Management option 2
• Diagnostic laparoscopy proceeding to
  immediate corrective surgery LASER and /or
  laparoscopic resection of diseased tissue

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Endometriosis

• CO 2 LASER Vs Diathermy
• depth of destruction
• accuracy
• collateral / unseen damage
• placebo effect
• cost

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Pelvic side wall
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EndometriosisTreatment by CO2 LASER
Classification I minimal II mild III
moderate IV severe AFS
Pregnancies 72 60 50 44
Improved pain 89 87 85 80
Del Pozo 1997
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Women with pain

• Drug therapy may relieve inflammation and reduce
  pain in early superficial disease but corrective
  surgery /- drug therapy is preferable (Padwick
  1999)
• rectovaginal, rectal and uterosacral lesions
  always need surgery
• endometriomas always need surgery
• abnormal anatomy and adhesions always need
  surgery

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Rectal involvement
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Endometriosis on the caecum
Endometriosis on the caecum
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Endometrioma
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LASER ablation of endometriosis

• endometriosis not cured by medication
• surgery may cure the younger woman
• Techniques
• ablate
• LUNA
• resect peritoneum
• ventrosuspension

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Before
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After
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But what if ?
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Requirements

• full RCOG accreditation
• MAS accreditation
• surgeon
• preceptor
• LASER certification

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What to expect

• Overnight stay (98)
• 3 puncture marks 5mm in length
• Voltarol / oral analgesics
• 1 to 2 weeks off work
• Mostly an immediate difference in pains
• Benefits of fertility are immediate

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West Herts Audit

• 150 women treated per year
• gt 500 women treated
• gt 95 diagnostic rate
• No acute complications
• No laparotomies
• One late sepsis
• Outcome measures ??

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Conclusion

• Endometriosis should be treated early and
  aggressively by surgical destruction or
  excision, ideally at laparoscopy. Drug therapy
  which is expensive, largely ineffective and has
  significant side-effects should be reserved for
  selected cases requiring post surgical
  maintenance therapy.
• Padwick 1999

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