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