Atypical endometriosis. Non pigmented endometriosis, Subtle endometriosis. infertility, sybfertility, chronic pelvic pain, dysparonia, laparoscopy, IVF, ICSI, Assisted reproduction, dysmenorrhea, pelvic congestion, danazol, GNRH analogue. laser ablation, NSAIDs.

1. BY
MAGDY ABDELRAHMAN MOHAMED
Lecturer of OB/GYN
2016

2.  Nomenclature:
 Atypical endometriosis.
 Subtle endometriosis.
 Non pigmented endometriosis

3. Defenition
 Endometriosis: the presence of functional
endometrium outside the uterine cavity.
 Atypical (Subtle) endometriosis:
Endometriotic lesions that lack the typical black-blue,
powder-burn appearance.
(Jansen & Russel,1986)

4. Typical lesions
(A): Black or bluish lesions:
 It results from tissue bleeding and retention
of blood pigment.

6. (B) Red lesions.
 Red flame-like lesions, glandular excrescences
and subovarian adhesions.

9. SUBTLE LESIONS
 I- RED lesions:
 Red flame-like lesions: more commonly affecting the
broad ligament & uterosacral ligaments.
 Glandular excrescences resemble the mucosal
surface of the endometrium.
 Areas with hypervascularization.

11. Typical lesion

12. II- White lesions:
 White opacification: appears as peritoneal scaring or as
circumscribed patches often thickened & sometimes raised.
 Subovarian adhesions.
 Yellow-brown peritoneal patches resembling café au lait
patches.
 Circular peritoneal defects: frequently occur in areas of the
pelvis which overlie loose connective tissue.

16. Non-visible endometriosis
 Biopsies were taken from visually normal
peritoneum of the uterosacral ligaments.
 Histological study revealed the presence of
endometriotic tissue in about 6% of infertile
women without endometriosis.
Nezhat F et al, 1991, Walter AJ et al, 2001.

17. Subtle endometriosis
 SE are more common than the classic
lesions in the adolescents with pelvic pain
(Davis et al,1993).
 The incidence decreases with age (Konincks
et al,1991).

19. Biological activity
 Subtle endometriosis are thought to be more
biologically active than typical forms.
 The red petechial implants produce twice the
amount of PGF than brown lesions, which in turn
produce more PGF than typical powder-burn
implants.

20. Clinical picture
1. Infertility.
2. Pain:
 Dysmenorhea,.
 Dysparunia.
 Chronic pelvic pain.

21. Clinical picture
Infertility.
SE is the most common single cause of
unexplained infertility.
(Propst & Laufer,1999).

22. Clinical picture
 Pain.
 Endometriosis occurs in approximately
70% of adolescent girls with chronic
pelvic pain not responding to
conventional medical therapy and the
majority of patients have stage I
disease.
(Ivo Brosens et al, 2013)

23. Diagnosis
 Standard laparoscopy.
 Negative laparoscopy results do not mean that the
patient has no E (Martin,1999)
 Laparoscopy under hydroflotation:
 Using lactated Ringer or normal saline introduced
into the pelvis (Laufer,1997).

24. Diagnosis
 Transvaginal hydrolaparoscopy:
 Superior to standard laparoscopy for detection of
Subtle endometriotic adhesions of the ovary .
 Histopathologic examination:
 Biopsy taken from suspected lesions.

26. Differential diagnosis
 Hemangiomas.
 Old suture.
 Reaction to oil-contrast medium.
 Epithelial inclusions.
 Secondary breast & ovarian cancer.
 Differentiation between SE & above lesions may be impossible
visually but may be achieved histologically

27. TREATMENT
 Aim of treatment:
 Reduce pain.
 Increase the possibility of pregnancy.
 Delay recurrence for as long as
possible.

28. Ideal Goal
 ASRM recommendation.
“Endometriosis should be viewed as a
chronic disease that requires a life-long
management plan with the goal of maximizing
the use of medical treatment and avoiding
repeated surgical procedures.” Fertil & Steril,
2008

31. Dienogest (Visanne)
 Synthetic oral progestogen with unique
pharmacological properties.
 highly selective for the progesterone
receptor .

32. Unique
 Strong progestational effects
 Moderate antigonadotrophic effects
 No androgenic, glucocorticoid or
mineralocorticoid activity.

33. Dienogest
 2mg once-daily.
 Can start at any day of menstrual
cycle.
 Must be continued regardless of
vag. Bleeding.

34. Advantages
 Dienogest appears to be safe and effective
when taken for up to 2 years.
 Dienogest is an oral therapy.
 Treatment of endometriosis with dienogest
is not inferior to that with GnRH agonists.

35. Mirina ( LNG-IUD)
 Treatment of choice for endometriosis
associated pain in women who do not wish
to conceive.
 Effective for at least 5 ys.
 Can be reapplied every 5 ys.
 No modifications in estrogen levels.
 Low-cost therapy.
 Fewer side effects than other progestogenic
agents.

36. Aromatase inhibitors
 Idea of use:
 In Normal endometrium: No detectable
levels of aromatase activity
 In endometriosis: An increased expression of
cytochrome P450 aromatase in endometrial
tissue.

37. Aromatase inhibitors
 Disadvantages:
 Cost
 Osteoporosis {decrease E in local
tissues}. Controversial

38. Selective Progesterone
receptor modulators (SPRM)
 Asoprisnil.
 It reduce pelvic pain as well as
dysmenorrhea.
 Its effect on bleeding pattern is dose-
dependent. (Chwalisz et al, 2004).
 Advantage: No estrogen deprivation.

39. Angiogenesis inhibitors
 Statins:
 Inhibit the growth of human endometrial stromal
cells in vitro (Piotrowski et al, 2006).
 Thalidomide (angiostatic & Immunomodulatory):
 Effective in women with relapsing endometriosis
(Scarpellini et al, 2002).

40. Atosiban