2. EndometriosisEndometriosis
Definition:Definition:
Presence of active functioning endometrial implants outsidePresence of active functioning endometrial implants outside
its normal place i.e uterine cavityits normal place i.e uterine cavity
Histology:Histology:
Endometrial Glands with Stroma +/- Inflammatory ReactionEndometrial Glands with Stroma +/- Inflammatory Reaction
6. Etiology:Etiology: Predisposing FactorsPredisposing Factors
HyperestrogenismHyperestrogenism
aa)) Fibroid &metropathia hemorrhagica.Fibroid &metropathia hemorrhagica.
b)b) Delayed marriage, infertility, nulliparaDelayed marriage, infertility, nullipara
c)c) estrogen secreting tumors of the ovary as granulosa &theca cell tumorsestrogen secreting tumors of the ovary as granulosa &theca cell tumors
d)d) prolonged estrogen therapy.prolonged estrogen therapy.
Uterine manipulation just before or during menses( IUD,Uterine manipulation just before or during menses( IUD,
D&C ,HSG,Intercourse)D&C ,HSG,Intercourse)
Interruption of menstual flowInterruption of menstual flow
*Outflow obstruction (impeforatehymen, vag.septum, Cx.stenosisor(impeforatehymen, vag.septum, Cx.stenosisor
atrsia)atrsia)
* Use of tampoons during menses
Enviromental pollutionsEnviromental pollutions
7. Etiology: TheoriesEtiology: Theories
Sampson: “Retrograde Menstruation”Sampson: “Retrograde Menstruation”
Celomic MetaplasiaCelomic Metaplasia( irritating factorstransform derivatives( irritating factorstransform derivatives
of celom into endometrium)of celom into endometrium)
Combined regurge /metaplasiaCombined regurge /metaplasia
Hematologic /Lymphatic SpreadHematologic /Lymphatic Spread
DiverticulartheoryDiverticulartheory (uterinecont. leadsto dipping of endo.(uterinecont. leadsto dipping of endo.
Into myomert.)Into myomert.)
8. EtiologyEtiology
Genetic FactorsGenetic Factors (run in families)(run in families)
Immune FactorsImmune Factors (weak immunity leave(weak immunity leave
endomertial fragmentsin pelvisto grow)endomertial fragmentsin pelvisto grow)
Iatrogenic direct implantation(Iatrogenic direct implantation( atat
CSscar and Episiotomy scar )CSscar and Episiotomy scar )
9. Hormonal theoryHormonal theory
TThe initial genesis of endometriosis based on the presence ofhe initial genesis of endometriosis based on the presence of
hormones, mainly oestrogen.hormones, mainly oestrogen.
Pregnancy causes atrophy of endometriosis through highPregnancy causes atrophy of endometriosis through high
progesteronelevel.progesteronelevel.
Regression also followsoophorectomy and irradiation.Regression also followsoophorectomy and irradiation.
Endometriosis is rarely seen before puberty and it regresses afterEndometriosis is rarely seen before puberty and it regresses after
menopause.menopause.
Hormones with antioestrogenic activity also suppressHormones with antioestrogenic activity also suppress
endometriosisand areused therapeutically.endometriosisand areused therapeutically.
35. Ultrasonic diagnosisUltrasonic diagnosis
Sonographic FeaturesSonographic Features ::
Endometritic cysts ,fine homogeneous, uniform, granularEndometritic cysts ,fine homogeneous, uniform, granular
echoes, anechoic, single or multiple, unilateral orechoes, anechoic, single or multiple, unilateral or
bilateralbilateral
On Doppler: no vascularity within themassOn Doppler: no vascularity within themass
39. Classification / StagingClassification / Staging
Several Proposed SchemesSeveral Proposed Schemes
Revised AFS System: Most Often UsedRevised AFS System: Most Often Used
Ranges from Stage I (Minimal) to Stage IVRanges from Stage I (Minimal) to Stage IV
(Severe)(Severe)
Staging Involves Location and Depth ofStaging Involves Location and Depth of
Disease, Extent of AdhesionsDisease, Extent of Adhesions
40.
41. AFS scoring (1985)AFS scoring (1985)
Stage1 (1-5), II (6-15), III (16-40), IV (> 40)Stage1 (1-5), II (6-15), III (16-40), IV (> 40)
42. Treatment: Overall ApproachTreatment: Overall Approach
RecognizeGoals:RecognizeGoals:
–– Pain ManagementPain Management
–– Preservation / Restoration of FertilityPreservation / Restoration of Fertility
Discusswith Patient:Discusswith Patient:
–– Diseasemay beChronic and Not CurableDiseasemay beChronic and Not Curable
–– Optimal Treatment Unproven or NonexistentOptimal Treatment Unproven or Nonexistent
44. Treatment of EndometriosisTreatment of Endometriosis
Management of painManagement of pain
– SurgerySurgery
– Medical therapyMedical therapy
Treatment of infertilityTreatment of infertility
– SurgerySurgery
– Ovulation inductionOvulation induction
– Assisted reproductive technologyAssisted reproductive technology
45. Treatment of PainTreatment of Pain
MedicalmanagementMedicalmanagement
– Oral contraceptives, progesterone, danazolOral contraceptives, progesterone, danazol
– GnRHagonist with add-backGnRHagonist with add-back
– Aromatase inhibitors - letrozoleAromatase inhibitors - letrozole
– NSAIDNSAID
46. Management of PainManagement of Pain
SurgicaltreatmentSurgicaltreatment
– Ablation of endometrial implantsAblation of endometrial implants
– Lysis of adhesionsLysis of adhesions
– Ablation of uterosacral nervesAblation of uterosacral nerves
– Resection of endometriomasResection of endometriomas
CombinedsurgicalandmedicaltreatmentCombinedsurgicalandmedicaltreatment
47. CHOICES OF MEDICALCHOICES OF MEDICAL
THERAPYTHERAPY
Drug group Example Side effects
1 Progestogens Medroxyprogesterone
Duphaston
Norculot
Mood swing
Nausea
bloatedness
2 Danazol
(synthetic androgen)
Danocrine Hoarseness
Hirsuitism, acne
3 Oral contraceptives Any OCPs Weight gain, bloatedness
4 GnRH analogue Zoladex (Goserelin)
Lucrin
Vasomotor symptoms/
osteoporosis
48. Continuous OCPsContinuous OCPs
COCPs act by ovarian suppression leading toCOCPs act by ovarian suppression leading to
Pseudopregnancy statePseudopregnancy state
?MinimizesRetrogradeMenstruation?MinimizesRetrogradeMenstruation
Choose OCPs with Least Estrogenic Effects,Choose OCPs with Least Estrogenic Effects,
Maximal Androgenic / Progestin EffectsMaximal Androgenic / Progestin Effects
(Marvelon)(Marvelon)
49.
50. ProgestinsProgestins
All progestational agents act by decidualization andAll progestational agents act by decidualization and
atrophy of theendometrium.atrophy of theendometrium.
MPA 10-30 mg/dayMPA 10-30 mg/day
DP150 mg Semi-MonthlyDP150 mg Semi-Monthly
TheLNG-IUS(Mirena)TheLNG-IUS(Mirena)
GestrinoneGestrinone
Dieno gest (Visanne) 2 mg/dayDieno gest (Visanne) 2 mg/day
Side-Effects: AUB, Mood Swings, Weight Gain,Side-Effects: AUB, Mood Swings, Weight Gain,
AmenorrheaAmenorrhea
51.
52. DanazolDanazol
Weak AndrogenWeak Androgen
SuppressesLH / FSHSuppressesLH / FSH
CausesEndometrial Regression, AtrophyCausesEndometrial Regression, Atrophy
ExpensiveExpensive
The recommended dose is 600-800 mg/dThe recommended dose is 600-800 mg/d
Side-Effects: Weight Gain, Masculinization,Side-Effects: Weight Gain, Masculinization,
Occ. Permanent Vocal ChangesOcc. Permanent Vocal Changes
53.
54. GnRH-aGnRH-a
Initially StimulateFSH / LH ReleaseInitially StimulateFSH / LH Release
Down-RegulatesGnRH Receptors–”Pseudomenopause”Down-RegulatesGnRH Receptors–”Pseudomenopause”
Go serelin, Tripto relin, Buserelin, Naserelin, andGo serelin, Tripto relin, Buserelin, Naserelin, and
leupro lide acetateleupro lide acetate arethecommonly used agonists.arethecommonly used agonists.
ExpensiveExpensive
UseLimited by Hypoestrogenic EffectsUseLimited by Hypoestrogenic Effects
May beCombined with Add-Back therapyMay beCombined with Add-Back therapy
55.
56. Medical treatmentMedical treatment
Interferons:Interferons:
combination with GnRH have resulted in higher cumulativecombination with GnRH have resulted in higher cumulative
pregnancy ratesand monthly fecundity ratespregnancy ratesand monthly fecundity rates
SERMs:SERMs:
Selective antiestrogenic activity on the endometrium, agonistSelective antiestrogenic activity on the endometrium, agonist
activity on bonesand lipoproteinsactivity on bonesand lipoproteins eg: Tamoxifeneg: Tamoxifen
57. Indications:Indications:
Mild Endometriosisassociated with infertilityMild Endometriosisassociated with infertility
Endometrioma>4 cm in diameterEndometrioma>4 cm in diameter
Endometriosisof rectovaginal septum or rectal wallEndometriosisof rectovaginal septum or rectal wall
Failed Medical therapyFailed Medical therapy
Intolerablesideeffectsof medical therapyIntolerablesideeffectsof medical therapy
SURGICAL MANAGEMENTSURGICAL MANAGEMENT
58. Surgical treatmentSurgical treatment
Surgical carecan beclassified as:Surgical carecan beclassified as:
ConservativeConservative when reproductive potential iswhen reproductive potential is
retainedretained
SemiconservativeSemiconservative when reproductive ability iswhen reproductive ability is
eliminated but ovarian function isretainedeliminated but ovarian function isretained
RadicalRadical when the uterus and ovaries arewhen the uterus and ovaries are
removed.removed.
