endometriosis - Endometriosis Endometriosis David Blair...

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Unformatted text preview: Endometriosis Endometriosis David Blair Toub, M.D. Department of Obstetrics and Gynecology Department Pennsylvania Hospital Pennsylvania Endometriosis s Definition: Ectopic Endometrial Tissue s True Incidence Unknown: ? 1-5% s Does NOT Discriminate by Race s Histology: Endometrial Glands with Stroma Histology: +/- Inflammatory Reaction +/- Signs and Symptoms s Chronic Pelvic Pain, Dysmenorrhea s Abnormal Uterine Bleeding s Infertility s Deep Dyspareunia s Pelvic Mass (Endometrioma) s Misc: Tenesmus, Hematuria, LBP, Misc: Hemoptysis Hemoptysis Prevalence Prevalence • Surgical Series (Uncontrolled) · 1 Ð 53% · Surgical Series (Controlled) · 23 Ð 47% (Infertile) · 1 Ð 5% (Fertile) · 6.2 Ð .9% 7 · Population-Based Studies · Epidemiological Study · 0.25 new cases/1000 w oman-years · Prevalence = 7.5% · Endometriosis Affects ~5 Million Women, 30-40% are Infertile • Su rg i cal S er i s (Un co n t ro l e d) e · 1 Ð5 3 % · Su rg i cal S er i s (C o nt ro l l ed ) e · 2 3 Ð4 7% (In fert i l e) · 1 Ð5 % (F ert i l e) · 6 . 2 Ð7 . % 9 · Po p ul a t o n -B as ed St u d i s i e · E i d em i l o gi c al S t d y p o u · 0 . 25 n ew c ase s/ 1 00 0 w o man -y ea rs · P re va l en ce = 7 . % 5 · E n d om et ri o si s Affec t s ~5 M i l l i n W om en , 30 -4 0 % o a re In fert i l e Age at Diagnosis Age 36 –45 15% > 45 3% 26 –35 52% < 19 6% 19 – 25 24% Etiology: Theories Etiology: s Sampson: “Retrograde Menstruation” s Hematologic Spread s Lymphatic Spread s Coelomic Metaplasia s Genetic Factors s Immune Factors s Combination of the Above No Single Theory Explains All Cases of Endometriosis No Diagnosis s Laparoscopy (“Gold Standard) s Laparotomy s Inconclusive: CA-125, Pelvic Exam, Inconclusive: History, Imaging Studies History, s Biopsy Preferable Over Visual Inspection Appearance Appearance Endometriosis May Appear sBrown sBlack (“Powderburn”) sClear (“Atypical”) Endometriosis May Be Associated with Endometriosis Peritoneal Windows Peritoneal Treatment: Overall Approach Treatment: s Recognize Goals: Recognize – Pain Management – Preservation / Restoration of Fertility s Discuss with Patient: – Disease may be Chronic and Not Curable – Optimal Treatment Unproven or Nonexistent Optimal Classification / Staging Classification s Several Proposed Schemes s Revised AFS System: Most Often Used s Ranges from Stage I (Minimal) to Stage IV Ranges (Severe) (Severe) s Staging Involves Location and Depth of Staging Disease, Extent of Adhesions Disease, Pain Management: Medical Therapy Therapy s NSAIDs s OCPs (Continuous) s Progestins s Danazol s GnRH-a s GnRH-a + Add-Back Therapy s Misc: Opoids, TCAs, SSRIs Continuous OCPs Continuous s “Pseudopregnancy” (Kistner) s ? Minimizes Retrograde Menstruation s Lower Fertility Rates than Other Medical Lower Treatments Treatments s Choose OCPs with Least Estrogenic Choose Effects, Maximal Androgenic / Progestin Effects Effects Progestins Progestins s May be as Effective as GnRH-a for Pain Control s MPA 10-30 mg/day, DP 150 mg Semi-Monthly s May be Taken Long-Term s Relatively Inexpensive s Side-Effects: AUB, Mood Swings, Weight Gain, Side-Effects: Amenorrhea Amenorrhea Danazol Danazol s Weak Androgen s Suppresses LH / FSH s Causes Endometrial Regression, Atrophy s Expensive s Side-Effects: Weight Gain, Masculinization, Side-Effects: Occ. Permanent Vocal Changes Occ. GnRH-a GnRH-a s Initially Stimulate FSH / LH Release s Down-Regulates GnRH Down-Regulates Receptors–”Pseudomenopause” Receptors–”Pseudomenopause” s Long-Term Success Varies s Expensive s Use Limited by Hypoestrogenic Effects s May be Combined with Add-Back (? >1 May Year ) Year Surgical Treatment (Laparoscopy / Laparotomy) (Laparoscopy s s Excision sí / Fulgeration no! Excision sí no! Resection of Endometrioma s Lysis of Adhesions, Cul-de-sac Reconstruction s Uterosacral Nerve Ablation s Presacral Neurectomy s Appendectomy s Uterine Suspension (? Efficacy) s Hysterectomy +/- BSO Issues Issues s ? Removal of Ovaries at Hysterectomy Removal s ? Need for Progestins if ERT Given s ? Adjuvant Treatment Postoperatively s ? Lupron Challenge Test for Diagnosis s ? Is Endometriosis Best Treated Surgically, Is Medically or Both Conclusion Conclusion s Endometriosis is a Common, Chronic Endometriosis Disease s Typical Symptoms Include Pain, Infertility, Typical Abnormal Uterine Bleeding Abnormal s The Optimal Treatment Remains Unclear s Surgical Excision is the Most Efficacious Surgical Approach with Respect to Fertility Approach s Better Medical Therapies are Needed ...
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