Download - The Modern Management of Endometriosis
The Modern Management of Endometriosis
Malcolm Padwick
What is it ?
The presence of endometrial tissue outside of the uterine cavity
• cul-de-sac
• rectovaginal septum
• surface of rectum
• fallopian tubes and ovaries
• uterosacral ligaments
• bladder
• pelvic side wall
Is it inherited?
• 6 to 8 fold increase risk in sisters compared to unrelated women
• affected sisters are more likely to have severe disease
• OXEGENE study ongoing
• ovarian cancer link
• racial
Aetiology
• Retrograde menstruation
• tissue transplantation
• peritoneal cell metaplasia
• venous spread
• lymphatic spread
• immune failure
Incidence
• At sterilisation 2 to 5 % have endometriosis
• 25 to 50 % of women investigated for infertility
• estimated 5 million women in USA
• 6 to 7 % of all females
Endometriosis symptoms
dysmenorrhoea
pelvic pain
infertility
dyspareunia
menstrual irregularities
other cyclic bleeding
70%
40%
35%
33%
15%
1-2%
Endometriosis
Diagnosis
• laparoscopy
The natural progression
Lesions
Clear mean age 21.5
Red
Black mean age 31.9
disease is progressive in 47 - 64% of women and in 20% of treated women (Redwine)
Endometriosis and Fertility
• 30 to 40 % of women with endometriosis are infertile
• may be obvious anatomical abnormalities
• hormonal E2 reduced LH blunted
• multicystic ovaries
• Luteinized Unruptured Follicle X 3
• peritoneal fluid, macrophages, cytokines, interferon C3, C4 are all increased
• plasma embryotoxic in 78% of cases
EndometriosisManagement options 1Diagnostic laparoscopyDrugs• OCP• Provera• Danazol / Gestrinone• GNRH analoguesSurgery• Hysterectomy with BSO
Endometriosis and Fertility
Hormonal or antihormonal therapy has no beneficial effect
on fertility either alone or as an adjunct to surgery ( RCOG recommendation)
only surgical ablation or excision of disease will restore fertility ( RCOG recommendation)
Endometriosis
Management option 2
• Diagnostic laparoscopy proceeding to immediate corrective surgery; LASER and /or laparoscopic resection of diseased tissue
Endometriosis
CO 2 LASER Vs Diathermy
• depth of destruction
• accuracy
• collateral / unseen damage
• placebo effect
• cost
Pelvic side wall
EndometriosisTreatment by CO2 LASER
Classification
I minimalII mildIII moderateIV severe
AFS
Pregnancies
72%60%50%44%
Improved pain
89%87%85%80%
Del Pozo 1997
Women with pain
• Drug therapy may relieve inflammation and reduce pain in early superficial disease but corrective surgery +/- drug therapy is preferable (Padwick 1999)
• rectovaginal, rectal and uterosacral lesions always need surgery
• endometriomas always need surgery
• abnormal anatomy and adhesions always need surgery
Rectal involvement
Endometriosis on the caecumEndometriosis on the caecum
Endometrioma
LASER ablation of endometriosis
• endometriosis not cured by medication
• surgery may cure the younger woman
Techniques
• ablate
• LUNA
• resect peritoneum
• ventrosuspension
Before
After
But what if ?
Requirements
• full RCOG accreditation
• MAS accreditation
– surgeon
– preceptor
– LASER certification
What to expect
• Overnight stay (98%)
• 3 puncture marks 5mm in length
• Voltarol / oral analgesics
• 1 to 2 weeks off work
• Mostly an immediate difference in pains
• Benefits of fertility are immediate
West Herts Audit
• 150 + women treated per year
• > 500 women treated
• > 95% diagnostic rate
• No acute complications
• No laparotomies
• One late sepsis
• Outcome measures ??
Conclusion
Endometriosis should be treated early and aggressively by surgical destruction or excision, ideally at laparoscopy. Drug therapy which is expensive, largely ineffective and has significant side-effects should be reserved for selected cases requiring post surgical maintenance therapy.
Padwick 1999