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1-5% Does NOT Discriminate by Race Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction
Chronic Pelvic Pain, Dysmenorrhea (90%) Abnormal Uterine Bleeding Infertility (55% ) Deep Dyspareunia Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, LBP, Hemoptysis
36 45 15%
> 45 3%
< 19 6%
19 25 24%
26 35 52%
Sampson: Retrograde Menstruation Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the Above
Laparoscopy (Gold Standard) Laparotomy Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies Biopsy Preferable Over Visual Inspection
Recognize Goals: Pain Management Preservation / Restoration of Fertility Discuss with Patient: Disease may be Chronic and Not Curable Optimal Treatment Unproven or Nonexistent
IS TREATMENT ALWAYS REQUIRED? WHO NEEDS TREATMENT? DOES ANY TREATMENT REALLY WORK? DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?
ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE SPONtan REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT
MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSISPERSISTENCE, REGRESSION AND PROGRESSION
ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT LAPAROSCOPIC ABLATION OF VISIBLE ENDOmetriosis IN INFERTILE WOMEN IS ASSOCiate WITH SIGNIFICANTLY INCREASED FERTILITY RATES
NOT PRECISELY KNOWN2-5% 20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMEN BUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION 52% OF TEENAGES WITH Chronic Pelvic Pain SYNDROME
Single/nulliparous Early menarche Non oral contraception Non smoker shorter cycle/longer duration of flow Dysplastic naevus syndrome, melanoma
Increased PGs
NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Misc: Opoids, TCAs, SSRIs
Pseudopregnancy (Kistner) ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Treatments Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects
May be as Effective as GnRH-a for Pain Control MPA 10-30 mg/day, DP 150 mg Semi-Monthly May be Taken Long-Term Relatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea
PSYCO-PHYSICAL TREATMENTSACCUPUNCTURE, MASSAGE, RELAXATION, TENS EXERCISE ANTI-OESTROGEN DRUGS LAPAROSCOPY/ OPEN SURGERY
Weak Androgen Suppresses LH / FSH Causes Endometrial Regression, Atrophy Expensive Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes
Initially Stimulate FSH / LH Release Down-Regulates GnRH Receptors Pseudomenopause Long-Term Success Varies Expensive Use Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1 Year )
ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITE SHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASE RESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENT DOES NOT DEAL WITH ADHESIONS
n 235 418
65%
20
912
257
Endometriosis is a Common, Chronic Disease Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious Approach with Respect to Fertility Better Medical Therapies are Needed