ENDOMETRIOSIS

WHAT IS THE GENERAL PRACTICE APPROACH?

FIRST – A FEW QUESTIONS!

IS TREATMENT ALWAYS REQUIRED?WHO NEEDS TREATMENT?DOES ANY TREATMENT REALLY WORK?DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?

I DON’T HAVE THE ANSWERS

ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASESPON REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

HOWEVER----

MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRDCOMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UPPREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSIS—PERSISTENCE, REGRESSION AND PROGRESSION

AND ALSO---------

ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRTLAPAROSCOPIC ABLATION OF VISIBLE ENDO IN INFERTILE WOMEN IS ASSOC WITH SIGNIFICANTLY INCREASED FERTILITY RATESTHERE IS NO DATA REGARDING EARLY INTERVENTION WRT PREVENTION

PREVALENCE

NOT PRECISELY KNOWN—2-5%20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMENBUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION52% OF TEENAGES WITH CPP SYNDROME

Familial association

Relative Risk to siblings 2.3 overall

Relative Risk to sibs if severe endo 15

Risk factors

Single/nulliparousEarly menarcheNon oral contraceptionNon smoker shorter cycle/longer duration of flowDysplastic naevus syndrome, melanoma

symptoms

90% severe dysmenorrohoea70% chronic pelvic pain75% dyspareunia55% infertility

Infertility mechanisms

Adhesions distorsion

Increased PGs

Cell mediated gamete inj

Defective folliculogenisis

Chronic salpingitis

Activated macrophag

Increased prev. ABs

LUFFS

Altered tubal motil

Cytokines Fertilization failure

hyperprolactinaemia

Impaired oocyte pick up

Sperm phagocytosed

Early spon abortion

Luteal phase deficency

Treatment of pain

NSAIDS: all significantly better than placebo, studies vary which one is bestNaproxen >mefanemic acid>aspirinNaproxen=ibuprofenNaproxen only drug with significant SEs

treatment of menstrual painTreatment level of evidenceSimple analgesics 1Herbal remedies 1 alcohol 2Antidepressants/anxiolytics 2OCPs 1NSAIDS 3

ENDOMETRIOSIS PAIN

PSYCO-PHYSICAL TREATMENTS-ACCUPUNCTURE, MESSAGE, RELAXATION, TENSEXERCISEANTI-OESTROGEN DRUGSLAPAROSCOPY/ OPEN SURGERY

LIMITATIONS OF DRUG THERAPY

ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITESHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASERESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENTDOES NOT DEAL WITH ADHESIONS

META-ANALYSIS MIN/MILD ENDOMETRIOSIS

PREG RATE

n FOLLOW-UP

NO TREAT

44% 235 0.5-3

DRUG THERAPY

41% 418 1- 5

SURGERY 65% 912 1 - 6IVF 20 257