Endometriosis is a chronic gynecologic disorder that commonly manifests as chronic pain and infertility. It affects 6 to 10 percent of women of reproductive age, and it is present in approximately 38 percent of women with infertility and in up to 87 percent of women with chronic pelvic pain. It is thought to develop from attachment and implantation of endometrial glands and stroma on the peritoneum as a result of retrograde menstruation. Endometrial lesions result from overproduction of prostaglandins and estrogen, which leads to chronic inflammation. The mechanism by which infertility occurs in women with early-stage endometriosis is not clear. Oxidative stress and higher concentration of inflammatory cytokines may affect sperm function in several ways, including causing sperm DNA damage. The abnormal peritoneal environment can also cause abnormalities in oocyte cytoskeleton function. In more advanced endometriosis with ovarian cysts and adhesions, the anatomic abnormalities can impair tubal function. Diagnostic evaluation of women with pelvic pain should include a thorough history and physical examination to rule out other gynecologic causes of pain. Nongynecologic causes (e.g., irritable bowel syndrome, interstitial cystitis, urinary tract disorders) can be ruled out with appropriate testing and referrals, if necessary. Definitive diagnosis of endometriosis can be made only by histology of lesions that have been removed surgically. Imaging studies cannot be used to diagnose endometriosis, but they can be useful in patients with pelvic or adnexal masses. Ovarian endometriomas typically appear on ultrasonography as cysts that contain low-level homogeneous internal echoes consistent with old blood. Imaging alone seems to be highly predictive in differentiating ovarian endometriomas from other adnexal masses. Transvaginal ultrasonography is the preferred imaging modality to determine the presence of endometriosis and deeply infiltrating endometriosis of the rectum or recto-vaginal septum. Magnetic resonance imaging should be reserved for patients with equivocal ultrasound results and in whom rectovaginal or bladder endometriosis is suspected.Progestins, danazol, extended-cycle combined oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) agonists can be used for initial treatment of pain in women with suspected endometriosis. However, recurrence rates are high after the medication is discontinued. If initial therapy is unsuccessful, diagnostic laparoscopy can be offered to confirm the diagnosis. Alternatively, empiric treatment with another suppressive medication is an option. Empiric therapy with a three-month course of a GnRH agonist is appropriate if initial treatment with oral contraceptives and NSAIDs is unsuccessful. It is important to explain to the patient that response to empiric therapy does not confirm the diagnosis of endometriosis.

1. MEDICAL MANAGEMENT OF ENDOMETRIOSIS
DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
DR APURVA MUKHERJEE MBBS
1

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Organizing secretary AMWICON – 2019
 Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group,
Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 VIDARBHA RATNA PURASKAR - 2019
Past Position
 Vice President of NOGS(2016-2017)
 Organizing joint secretary ENDO-GYN
 Vice President IMA Nagpur (2017-2018)
 Organizing joint secretary ENDO-GYN 2019
2DR ALKA MUKHERJEE

3. Introduction
• Endometriosis - Enigmatic disease - chronic, progressive,
recurrent, debilitating immune mediated disease,
• Definition- The presence of endometrial glands and stroma,
outside the uterine cavity which induces chronic
inflammatory reaction.
• General incidence - around 10 %
• Among the infertile women - 25 – 48 %
• 176 million women or even more in the world suffer from
endometriosis.
• The main symptoms are dysmenorrhoea, dyspareunia,
dysuria, dyschezia, abnormal uterine bleeding and difficulty
in conception.
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4. PATHOPHYSIOLOGY
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7. DIFFERENTIAL DIAGNOSIS FOR PELVIC PAIN
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8. • The dependence of endometriosis on the woman's cyclic
production of menstrual cycle hormones provides the basis for
medical therapy.
• Medications currently recommended include gonadotropin-
releasing hormone (GnRH) agonists, progestins, oral contraceptive
pills, and androgens.
• Combined low dose hormonal contraceptives - Oral Pills, Use of
vaginal contraceptive ring or a transdermal [oestrogen/progestin]
patch, Continuous use of COC
• Each of these interrupts the normal cyclic production of
reproductive hormones. There are some data supporting the use of
aromatase inhibitors for refractory or recurrent endometriosis.
Medical management of endometriosis
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9. Medical management of endometriosis
a) Empirical treatment, in suspected cases of endometriosis,
to be started, based on the symptoms, after counseling the
women thoroughly.
b) GDG recommends medical therapy for patients of
endometriosis for
1.Prevention of recurrence following surgery and for long
term follow up
2.If recurrence occurs
3.In patients who refuse surgery (Evidence level GPP)
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10. Clinicians should counsel women with
symptoms presumed to be due to
endometriosis [CPP, dysmenorrhoea and
dyspareunia] thoroughly.
Empirical medical management includes
NSAID’s, OCP’s and GnRH agonists. (Evidence
level GPP)
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11. 1. NSAIDs
1. NSAID’s or other analgesics to reduce endometriosis
associated pain should be considered.(Evidence level
GPP)
2. Mefenemic acid is the commonly used NSAIDs
(Evidence level GPP)
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12. Managing endometriosis with hormone
therapy
• Hormone therapies may be used as a treatment for many
stages of endometriosis, or as a combined therapy,
either before or after surgery, for minimal to severe
endometriosis.
• Hormone therapies aim to reduce pain and the severity
of the endometriosis by:
• suppressing the growth of endometrial cells
• stopping any bleeding, including the period.
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13. 2.COC
b) Use of combined low dose hormonal contraceptives
reduces EAPP. [Evidence level-B]
1) Oral Pills [Evidence Level – B]
2) Use of vaginal contraceptive ring or a transdermal
[oestrogen/progestin] patch for EAPP has been
recommended {Evidence level-C]
3) Continuous use of COC may be considered for EAPP.
[Evidence level-C]
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14. • Reduce or eradicate endometrial implants by suppressing
ovulation and the production of oestrogen and
progesterone by the ovaries.
• The low levels of oestrogen in the body - the endometrial
implants are no longer stimulated to grow, and they
break down each month so they gradually shrink or 'dry
up'.
• Temporary chemical 'menopause'.
1)GnRH agonist is effective therapy for EAPP
2)Commonly used GnRh agonist - Leuprolide & Goserelin
[Evidence Level A]
3.GnRh agonist
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15. 3.GnRh agonist
3) Hormonal add-back therapy should be recommended
when GnRH agonist is used for long-term to prevent
bone loss and hypo-estrogenic symptoms [Evidence
level-A]
4) Addition of add-back therapy does not reduce the effect
of treatment for pain relief [Evidence level-A]
5) GnRh agonists in young girls less than 16 years - not
recommended due to adverse effects on BMD [
Evidence level GPP]
6) Vitamin D and Calcium supplementation -
recommended when patients are on GnRH agonist
(Evidence level GPP]
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16. 4. Use of progesterone
Suppress the growth of the endometrial tissue - shrink
gradually and disappear. Provide pain relief for up to 80%
MPA oral or depot, norethisterone acetate, dienogest or
danazol are indicated to reduce EAPP [Evidence level-A]
a. DMPA 150 mg or DMPA SC 104mg - every 3 months. -
Equally effective as GnRH agonists [Evidence level-A]
b. Dienogest at the dose of 2mg/day is as effective as GnRH
agonist but with much less side effects [Evidence level-A]
c. Subdermal implants [Etonogestrol] of depot
Progesterone can be used if available (Evidence level
GPP)
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17. d. Anti-Progestins like Gestrinone are not
commonly used (Evidence level GPP)
e. Levonorgesterol-releasing Intra-uterine system
reduces EAPP as second line [Evidence level-A-B].
It also helps in regressing associated adenomyosis
(Evidence level B)
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18. 5. Danazol
• a). Oral danazol is effective in treatment of
EAPP but serious androgenic side effects
limits its use (Evidence level GPP)
•b). Vaginal Danazol / IUCD loaded with
danazol may be an option and it is
recommended for DIE but it is currently not
available in India (Evidence level GPP)
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19. 6. Aromatase inhibitor
a). Anastrazole [1mg] and Letrozole [2.5mg] can
be given daily for 12 weeks with Progesterone
add-back therapy [Evidence Level B]
7. Anti-Angigenic Therapy
Cabergolin; [0.5 mg weekly twice for 3 months]
reduced EAPP in early lesions and reduces the size
of endometrioma, with comparable effect to LHRH
agonist
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20. 8.Lifestyle Modification
a. Dietary modifications and exercise have
some influence on the severity of symptoms
[Evidence level GPP]
b.Psychotherapy may be beneficial in EAPP
[Evidence level GPP]
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21. HOW IT HELPS WHAT YOU CAN DO
Physical activity and exercise Some gentle activity to keep
your body moving can help to
ease pain
About 20-30 minutes of physical
exercise on most days of the
week is recommended, unless
you have not exercised recently.
If that is the case, you should
begin with smaller amounts and
gradually build up as your fitness
improves
Sleep Having enough quality sleep
every night will help your
immune system function at its
best
•Reduce caffeine and alcohol
intake late at night
•Avoid heavy meals late at night
•Maintain regular timing for
going to bed and waking
Stress management and
relaxation
Finding ways to manage the
stress that endometriosis can
create is important for your
wellbeing
•Try gentle yoga techniques
•Try relaxation skills such as
mindfulness therapy
•Organise your day so you always
have some time out for yourself
•Seek help from a psychologist or
counsellor
Managing endometriosis with a healthy lifestyle
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22. c. There is some evidence to show that Yoga and
meditation help in alleviation of symptoms associated
with EAPP [Evidence level GPP]
d. Alternate therapies like acupuncture and Chinese
herbal medicine reduces EAPP and left to the choice of
the patient [Evidence Level-B]
• f.High frequency TENS may be effective in treatment of
EAPP[Evidence levelGPP]
• e. Multidisciplinary approach is strongly recommended
in EAPP [Evidencelevel GPP ]
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23. Endometriosis & natural therapies
• Alternative treatments, such as transcutaneous
electrical nerve stimulation (TENS), dietary
change, acupuncture and Traditional Chinese
Medicine (TCM), have not shown strong
evidence for management of endometriosis
pain. Scientific studies have not clearly
established either potential benefits and/or
harms. This is an emerging area, so evidence
may change over time.
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24. • Endotone is an efficacious herbal formulation for the management
of endometriosis.
• Endotone effectively delays and stops the proliferation of
endometrial cells. It reduces pain associated with dysmenorrhea and
dyspareunia. It also restores the fertility, reduces the emotional
distress and improves quality of life.
• Musta (Cyperus rotundus) – Controls the proliferation of
endometrial cells, reduces pain
Haridra (Curcuma longa) – Controls proliferation of endometrial
cells, reduces inflammation
Lodhra (Symplocos racemosa) – Improves the hormonal balance
Ashwagandha (Withania somnifera) – Reduces emotional distress,
improves quality of life
Twak (Cinnamomum cassia) – Preserves fertility
Shunthi (Zingiber officinale) – Reduces dysmenorrhea, pain and
inflammation
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28. Adolescent Endometriosis
• Adolescent girls (13 to 19 years) constitute around 3 to 5%
• Girls suffering from chronic pelvic pain - 70 – 80 % are
reported to have endometriosis.
• The presenting features differ from adult population. Most
of them present with severe dysmenorrhoea and school
absenteeism.
• Difficulties in diagnosis as most of them present with
atypical symptoms and are treated empirically.
• The diagnosis is often delayed in the adolescent girls for a
period of more than 6-8 years if high index of suspicion is not
there.
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29. 1. Suspect endometriosis in adolescents when they have severe
dysmenorrhoea, interfering with daily activities and school
absenteeism not responding to NSAIDS and OCPs when taken for
pain relief.
2 Early onset progressive dysmenorrhoea in adolescents should
be investigated for the possibility of Mullerian anomaly with
outflow tract obstruction
3 Diagnosis in adolescents are through history, physical
examination, risk factors and family history combined with imaging
technologies and biomarkers
4.USG and MRI may be done. This may confirm diagnosis only in
advanced lesions. Early lesions may not be picked out
5.When the adolescents do not respond to NSAIDS and OCPs,
diagnostic laparoscopy has to be done to confirm the diagnosis as
well as to treat.
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30. 6.Positive histology confirms the diagnosis, even though
negative histology does not exclude it.
7 Expectant management for adolescent endometriosis
when it is diagnosed incidentally, is debatable
8. Continuous use of OCPs for adolescents - safe and
effective for EAPP and can be used as first line of
treatment
9 . Progestins are also used for endometriosis
associated pelvic pain (EAPP) and have comparable
results with that of GnRH analogues and Danazol.
Newer progestins like dienogest may help to relieve
pain in adolescent girls and can be used for a longer
period.
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31. 9. GnRh agonists are used only for girls beyond 16 years
10 .When DMPA and GnRh are used, BMD reduction has to
be monitored
11 .LNG IUS can be used in sexually active adolescents as
second line of management
12 .Laparoscopy for endometriomas has to be balanced
carefully, to avoid the loss of ovarian reserve Vs pain relief.
13. First surgery should be done by an experienced surgeon
specialized in endometriosis, as adolescent endometriosis has
atypical findings
14. Long term follow up is a must to prevent recurrence
15. Continuous OCPs can reduce the recurrence.
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32. • Likely to recur after medical or surgical therapies
because the basic pathophysiology cannot be corrected.
a.Long-term post-operative OCP’s or progestins to
reduce the risk of recurrence
b. Post -operative use of GnRh agonist for 6 cycles
rather than 3 cycles prevent the recurrence of
endometriosis
c.Oral progestins (MPA, Dienogest, Danazol) are
effective in reducing pain and preventing the
growth of lesion after surgery Dienogest has added
advantage of being anti-inflammatory, anti-
angiogenic and anti-proliferative with less side
effects
Recurrent endometriosis
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33. First line of management of scar endometriosis –
a} wide excision of the mass.
b}Smaller lesions may respond to medical management
with drugs like progestins, OCP’s danazol, GnRh agonists
and dienogest
 {They can only reduce the symptoms but not the size of
the lesion.}
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34. ADENOMYOSIS
1.Adenomyosis is defined as a disorder characterized by the
presence of heterotopic endometrial glands and stroma in the
myometrium with hyperplasia of the adjacent smooth muscle
[Evidence level GPP]
2.Adenomyosis is considered relatively common but its exact
incidence has not been accurately determined and ranges from
5 % to 70 % in symptomatic women (Evidence level D]
3.There is increased incidence of adenomyosis in multiparous
women, women getting married at later age, and in women
who had spontaneous abortions undergoing multiple D&Cs.
Generally seen in 3rd
and 4th
decade and rarely seen in
adolescent girls. [Evidence level C]
4.The exact etiology and pathophysiology of uterine
adenomyosis is still unknown. [Evidence level GPP].
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35. • Diagnosis of adenomyosis - TVS, 3D, color Doppler and MRI [
Evidence level C]. MRI is more reliable than TVS and is essential
to plan for uterine sparing surgeries [Evidence level A].
6.Women with adenomyosis present with heavy uterine
bleeding and severe dysmenorrhoea.[ Evidence level
C].
7.Difficulty in conception - unclear how it causes
infertility
Management - Medical or surgical
Surgical management may be conservative or radical
Medical management includes COC’s, GnRh agonists,
Progestins (MPA, Dienogest, Danazol, LNG-IUS), SPRM’s
and SERM
2.Medical management avoids surgery but not very effective in
relieving pain [Evidence level B].
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36. NSAID’s - no effect on the disease and its progression - can be
given for pain relief who want to conceive[Evidence level GPP]
• GnRh provides symptomatic relief, reduces uterine volume and
allows spontaneous conception after cessation of therapy
[Evidence level C]
1.Pre-operative GnRh may reduce the size, vascularity and blood
loss during surgery.
2.This facilitates laparoscopy rather than laparotomy.
3.Sometimes during surgery there may be difficulty in delineating
the marginsand complete excision may be difficult.[Evidence
level C]
Dienogest may be useful in long- term treatment of symptomatic
adenomyosis [Evidence level B].
Oral MPA or injectable DMPA 150mg once in 3 months may be
cost effective in treatment of adenomyosis. [Evidence level A]
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37. LNG-IUS
1. Reduces uterine volume and relieves symptoms within a period
of 3 – 6 months [Evidence level C].
2. Improves quality of life when compare to hysterectomy
3. Relieves chronic pelvic pain associated with adenomyosis
Locally delivered Danazol may be used as an alternate treatment
for symptomatic adenomyosis.
Danazol loaded IUCD’s, rings and intra-cervical injections are
the newer methods of delivering Danazol locally
Continuous combined oral contraceptive pills show overall safety,
good efficacy and appreciable tolerability at low cost [Evidence
level B ].
SERMs and SPRMs have a limited role in clinical practice.[
Evidence level B]
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38. Aromatse inhibitors may be as effective as GnRh agonists
in improving the symptoms and reducing the volume of
adenomyosis [Evidence level B]
Uterine artery embolization may improve the
symptoms of Adenomyosis but recurrence may be
high [Evidence level A].
HIFU and Magnetic Resonance guided ultrasound
are effective ablative technique for symptomatic
adenomyosis
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39. • Medical management in the form of ovulation
suppression is ineffective in improving the pregnancy
rates
• In stage I and II endometriosis, treatment with super
ovulation and IUI improve fertility compared to
expectant management. Clinicians should take into
consideration, age, duration of infertility, ovarian
reserve and male factor
• COS using GnRh agonists or antagonists is effective
in IVF patients with mild to moderate endometriosis
and in those with endometrioma who did not undergo
surgery.
• Ultra-long protocol of GnRh agonists for a period of 3
– 6 months before ART improves the clinical
pregnancy rates
Endometriosis and Infertility
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40. Specific entity, Endometriotic lesions extending more than 5 mm
underneath the peritoneum
Suspect extra-genital endometriosis, when bleeding from
unusual sites e.g: epistaxis, cyclical hemopneumothorax,
haematochezia, haematuria, umbilical bleeding, and previous
scars are seen.
PHYSICAL WXAMINATION:
• P/V - all women suspected of endometriosis
• P/R - adolescents and or women without previous sexual
intercourse
a.Physical examination has poor sensitivity, specificity, and
predictive value
b.Rule out non endometriotic causes in patients complaining of
pelvic pain after thoroughly going through the findings of
combination of history, physical examination, and imaging
studies.
Deep infiltrating endometriosis
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41. Examination, or visible vaginal nodules in the posterior
vaginal fornix -best seen during menstruation.
Suspect presence of ovarian endometrioma in women if
adnexal masses are detected during clinical examination.
Absence of clinical evidence during examination does not
rule out the disease.
Apart from research settings, biomarkers are not
recommended for routine clinical use.
CA-125 may be of value – 1. to rule out ovarian malignancies
and presence of extensive peritoneal lesions.
2. In some cases it may be of
some value for treatment follow-up
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