Endometriosis

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Endometriosis

• District I ACOG Medical Student Education Module
  2009

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What is Endometriosis?

• Chronic condition.
• Characterized by the growth of endometrial tissue
  in other sites outside the endometrial cavity.
• Pelvic cavity
• Ovaries
• Uterosacral ligaments
• Pouch of Douglas

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What are the symptoms?

• Dysmenorrhea - recurrent painful periods
• Dyspareunia - painful intercourse
• Chronic lower abdominal and back pain
• Non-cyclic or cyclic pelvic pain
• Adnexal masses
• Subfertility
• Symptoms range from severe to minimal to no
  symptoms at all.

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How common is endometriosis?

• Incidence is 40-60 in women with dysmenorrhea.
• And 20-30 in women with subfertility.
• Most common age of diagnosis is 40.

Farquhar, C. Endometriosis Clinical Review.
BMJ 2007334249-53.
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What are the causes of endometriosis?

• Retrograde menstruation
• Postulated in the early 1920s by Dr Sampson.
• Many women experience retrograde menstruation but
  do not go on to develop endometriosis.
• This theory also fails to explain why
  endometriosis can be found in remote areas such
  as the lungs, breasts, lymph nodes and even the
  eyes.
• The transplantation theory
• That endometriosis spreads via the circulatory
  and lymphatic system.

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• Coelomic Metaplasia -
• This theory holds that certain cells, when
  stimulated, can transform themselves into a
  different kind of cells.
• The hereditary theory
• Women with family members who have endometriosis
  are more likely, or are susceptible to developing
  the disease.
• Environmental factors
• A great deal of research is clearly highlighting
  that women who are exposed to environmental
  toxins are at much greater risk of developing
  Endometriosis along with other serious health
  disorders.

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How do you diagnose endometriosis?

• Accurate history
• Dysmenorrhea, pelvic pain etc.
• Physical exam
• Tenderness in the posterior fornix or adnexal
  masses
• Laparoscopy is the only diagnostic test that can
  reliably rule out endometriosis.
• Gold standard.

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When do you perform laparoscopy?

• Severe pain over several months.
• Pain requiring systemic therapy.
• Pain resulting in days off from work or school.
• Pain requiring admission to the hospital.

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What are the medical treatment options?

• Oral contraceptives
• Progestins
• Androgenic agents
• GnRH analogues
• All suppress ovarian activity and menses and
  cause atrophy of the endometriotic implants.
• Base decision of treatment on side effect profile.

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• Endometriomas are not amenable to medical
  treatment.
• Randomized controlled trials that compare
  excision or drainage and ablation of
  endometriomas gt3 cm reported recurrence rates
  reduced and improved spontaneous pregnancy rates.

Sagsween M. Gonadotrophin releasing hormone
analogues for endometriosis bone mineral
density. Cochran Database Syst Rev 2003
(4)CD001297
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What does surgical management entail?

• Laparoscopy or open procedures.
• Requires excision or ablation (by laser or
  cautery) of the implants.
• Surgical excision of endometriosis results in
  improved pain relief and improved quality of life
  after 6 months compared with diagnostic
  laparoscopy alone.

Abbott J, Hawe J, Hunter D, Holmes M, Finn P,
Garry R. Laparoscopic excision of endometriosis
a randomized, placebo-controlled trial. Fertl
Steril 200482878-84.
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How often does endometriosis recur after surgery?

• Rate of recurrence is 20 after 5 years.

Redwine DB. Laparoscopic treatment of complete
obliteration of the cul-de-sac associated with
endometriosis long-term follow-up of en bloc
resection. Fertil Steril 200176358-65.
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What are the unanswered questions?

• Is medical or surgical management more effective?
• Does long term medical management reduce the
  recurrence of endometriosis?
• What is the benefit of surgery for rectovaginal
  disease?

Farquhar, C. Endometriosis Clinical Review.
BMJ 2007334249-53.