Endometriosis

Endometriosis

A benign condition in which endometrial glands and stroma are present outside the uterine cavity

Dysmenorrhea, dyspareunia, dyschezia

Triad of Endometriosis - the cyclical 3Ds

Retrograde menstruation (Sampson’s), hematologic spread, lymphatic spread, coelomic metaplasia, genetic factors, immune factors

While not a single theory explains endometriosis, what are the theories?

Monkey experiments (sutured cervix → endometriosis), increase risk with cervical/vaginal atresia, increased risk for early menarche/longer and heavier periods, decreased risk with low estrogen levels

What are some of the evidence for Sampson’s Theory of Endometriosis?

6-10 women of reproductive age (71-87% of women with chronic pelvic pain)

Epistats for Endometriosis

See it with yo eyeballs (diagnostic laparoscopy) with biopsy

Gold standard Diagnostic for Endometriosis 🏆

Black powder burn lesions (classic), red/white lesions, chocolate cyst (ovarian endometrioma) - can involved the bladder and infiltrate DEEP

Findings of Endometriosis at the time of Laparoscopy

NO

When it comes to endometriosis, does the amount of disease correlate with symptoms?

Fixed, retroverted uterus; uterosacral ligament nodularity, palpable adnexal mass (endometrioma)

What are some physical exam findings that are red flags for endometriosis?

Start medical treatment, follow up in 3-6 months to assess response (no response - refer to gyn)

IF endometriosis is suspected what can we do?

Expectant, medical, surgical, combo

What are some common management option for endometriosis?

NSAIDs, OCPs, Levonorgestrel-containing IUD, Progestins (Depot medroxyprogesterone acetate (DMPA) or norethindrone acetate), GnRH Agonist (DepoLupron/danazol)

Medical treatment for Endometriosis

Androgenic side effects (acne, hirsutism, myalgia); “chemical menopause” (hot flases, vaginal dryness, osteopenia)

ADRs for GnRH agonists?

Leuprolide, Buserelin, Nafarelin, Histrelin, Goserelin, Deslorelin

Amino acid substitutions of GnRH agonist helps inhibit rapid degradation, what are some examples of those with 2 substitutions?

Continue for more than 6 months provided that “add-back” therapy is started

If a patient is satisfied with treatment with GnRH agonist and symptoms are under control, what is the game plan?

Norethindrone acetate (5 mg), conjugated estrogen w/medroxyprogesterone acetate (0.625 mg/2.5 mg), transdermal estradiol w/medroxyprogesterone acetate (25 mcg/2.5mg)

What are some of the “add-back” therapies for endometriosis?

GnRH agonist (95% - progestins at 91%, Danazol at 88%, E+P at 86%)

Which medical treatment has the greatest relief of pain?

Definitive diagnosis, remove implants, prevent progression, relieve pain, enhance fertility

What are the goals of surgical treatment for endometriosis?

Laparoscopic/open surgery (excision of endometriomas over 3 cm)

If the patient desires future fertility, what are the surgical options

hysterectomy, bilateral salpingo-oophorectomy, and destruction/removal of all endometriotic disease

If the patient DOES NOT desire future fertility, what are the surgical options

decrease volume and vascularity, treat microscopic disease, obviate therapy in post-op period when chance for conception should be increased

Pre-op Rationale for combo surgical and medical

Treat microscopic disease, avoid extensive peritoneal injury and bleeding, reduce symptomatic recurrences

Post-op Rationale for combo surgical and medical

Recurrent pain (62% with ovarian tissue preservation or 11% with total TAH), Reoperation (13% with ovarian tissue preservation or 4% with total TAH),

What are the rates for symptoms recurrence for Endometriosis after treatment?