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Endometriosis (TREATMENT (TREATMENT OF PATIENTS WITH ENDOMETRIOSIS-RELATED…
Endometriosis
TREATMENT
- Laparoscopy as a method of choice (avoiding laparotomy) - surgery to improve fertility and removal of endometriosis
- Hormonally active drugs: gonadoliberin analogs (eg Leuprorelin, cave: add-on therapy to reduce the risk of bone loss - 1 mg 17-beta-estradiol, calcium and vitamin D3), progestogens alone (Dienogest, Lynestrenol) or in combination (COC-combined oral contraceptives), intrauterine device (IUD) containing Levonorgestrel, selective progesterone receptor modulators, aromatase inhibitors (cave: risk of bone loss), Danazole (cave: adrenal and anabolic effects, antibody-lowering effect, immunomodulatory effect)
- Assisted reproduction techniques do not cure endometriosis, but they provide the desired treatment effect in endometriotic women who undergo infertility
- Antiinflammatory drugs: prostaglandin synthesis inhibitors and non-steroidal anti-inflammatory drugs
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Differential dIAGNOSIS
Disorder
- Infection of the female genital tract
- Adnexitis, Ectopic pregnancy
- Ovarian cysts, Intraabdominal adhesions
- Retroflexion of the uterus
- The group of acute abdominal causes
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USG-TV
ovarian endometriosis
- Pelvic ultrasonography is the modality of choice for the investigation of women with chronic pain thought to be endometriosis-related as well as for the assessment of adnexal masses and deep endometriosis.
- Ultrasonography has high sensitivity (84–100%) and specificity (90–100%) in identifying ovarian endometriomas with their characteristic low-level, homogeneous, internal echoes.
- FEATURES:
Unilocular cysts
Cyst is filled with higher echogenic content
„BROKEN GLASS” PICTURE
Thickened and irregular internal capsule of cyst
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etiology
- Sampson’s theory (1927) – regurgitation of menstrual blood (retrograde menstruation) to the pelvic cavity (formation of endometriodal implants) - explains the majority of cases
- „Metaplastic” theory (Meyer, 1919, Gruenwald, 1942, Donnez, 1995)– reconstruction of normal celomic cells in a body cavity in endometrioid cells, it may occur spontaneously or be facilitated by chronic irritation as a result of retrograde menstruation - explains some rare cases
- disturbances in the environment of the peritoneal fluid- hormonal changes, immunological background, genetic predisposition
- Halban’s metastatic theory– spreading of cells to distant organs (lung, brain, lymph nodes, e.t.c.)
- Remains of Mueller's ducts- it becomes to differentiation during maturation and adolescence due to rise of estrogen or in case of relative imbalance between estrogen and male sex hormones (elderly obese men - cases in men)
- iatrogenic (implants of endometriosis after Cesarean section)
symptomatology
- Dysmenorrhea 60-80%
- Dyspareunia 25-50%
- Chronic pelvic pain 30-50%
- Infertility/subfertility 30-50%
- Irregular menstrual bleedings 10-30%
- Hematuria <2%
- NEURALGIA, SENSORY AND MOTOR DISTURBANCIES – SCIATIC AND OBTURATOR NERVES,
- (SUB)ACUTE ABDOMEN (?)
- RENAL OR URETHRAL COLIC (due to DIE)
- DYSURIA
- (SUB)ILEUS (due to DIE)
- CHRONIC CONSTIPATION
- OTHER SYMPTOMS (OTHER SITES AND ORGANS = LOCALIZATION OF IMPLANTS)
- CATAMENIAL - pneumothorax, hemoptysis
- Splenosis - autotransplantation of the splenic tissue after rupture of spleen. The implants mimic endometriosis during surgery (splenosis usually is asymptomatic)
risk factors
reproductive age
good socioeconomic conditions
early menarche
polimenorrhea, hypermenorrhea
genetics
Predisposing factors
- Hyperestrogenism (concomitant factors/causes)
a) Uterine fibroids (myomas) and heavy menstrual bleeding
b) Nulliparity
c) Estrogen-producing ovarian tumors: granulosa cell tumors, thecomas, long lasting estrogen therapy
- Anatomical defects (Muellerian tract stenosis i.e. transveres vaginal septum, cervical stenosis)
- Iatrogenic causes (dilatatio & curretage)
localization
- sacro-uterine ligaments (lateral anterior-posterior limitation of Doulgas pouch) 67%
- superficial ovarian implants 56%
- pelvic peritoneum of Douglas pouch 24%
- peritoneum of Morisson’s recessus 20%
- endometrioid cysts 20%
EXTERNAL ENDOMETRIOSIS
- TWO MAIN TYPES:
-SUPERFICIAL ENDOMETRIOSIS
IMPLANTS AND CYSTS
-DEEP INFLITRATING ENDOMETRIOSIS (DIE)
DEEP IMPLANTS (>5 MM), FIBROSIS
DIAGNOSIS
- DIAGNOSIS BASED ON A CLINICAL EXAMINATION AND IMAGING IS POSSIBLE
- ON THE BASIS OF CLINICAL SITUATION, EMPIRICAL TREATMENT CAN BE INPLEMENTED
- Laparoscopy should not be performed during hormonal treatment to avoid under-diagnosis
- Microscopic evidence of endometriosis can occur in the normal peritoneum
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- THE PRESENCE OF ENDOMETRIAL MUCOSA CELLS AND STROMA OUTSIDE THE UTERINE CAVITY (ECTOPIC ENDOMETRIUM), featuring with similar histological structure and hormonal activity as the normal endometrium
- EXTERNAL (Douglas pouch, uterine ligaments, peritoneal surfaces i.e. urinary bladder implants, pelvic peritoneum nodules, endometrioid cysts, deep infiltrating endometriosis)
- INTERNAL (uterine muscle=adenomyosis (in 50% of cases), foci of endometriosis in the cervix uteri)
- endometrioSIS CLASSIFICATION (AMERICAN FERTILITY SOCIETY)
most common used
stages from I (minimal) to IV (severe)
Evaluation is based on the occupied organ types, size of foci, adhesions
STAGE I (minimal): 1 – 5. poiNTS,
STAGE II (mild): 6 – 15. POINTS
, StAGE III (moderate): 16 – 40. POINTS
, StAGE IV (severe): > 40 POINTS
