Endometriosis for Undergraduates Max Brinsmead MB BS Ph
Endometriosis for Undergraduates Max Brinsmead MB BS Ph. D November 2017
Historical Perspective n 1970’s “A disease of uncertain aetiology whose relevance to fertility is uncertain” n 1980’s “A common condition that may be present in as many as one woman in four” n 1990’s Much more known about aetiology. Principles of management emerging. n 2000+ n Evidence-based management
Endometriosis is: n Ectopic endometrium i. e. “internal menstruation” n Requires laparoscopy +/- biopsy for diagnosis n Activity is more important than appearance n Symptoms do not always correlate with grading
Symptoms of Endometriosis n The Classic Triad… n Dysmenorrhoea n n Dyspareunia n n Sufficient to interfere with daily life Deep pain during or after sexual intercourse Infertility
Symptoms of Endometriosis n But consider also… n n n Pre menstrual staining Pain with defaecation during menstruation Period-related urinary symptoms including haematuria Intermenstrual chronic pelvic pain Disordered cycles Family history
Diagnosis of Endometriosis n n A Careful History (The most important) Rule out other Causes of Symptoms (The next most important) n n n Examination (not much help) Ultrasound (of little value) MRI (useful for rectovaginal deposits) Laparoscopy (The gold standard) Serum CA 125 (Lacks sensitivity) Iridology (a good guess!)
Differential Diagnosis: n Primary Dysmenorrhoea n Irritable Bowel Syndrome n Ovulation Pain n Pelvic Inflammatory Disease n Psychosexual Problems
Aetiology n Two Main Theories: n n n Retrograde menstruation Peritoneal metaplasia Predisposing Factors n n n Familial predisposition Disordered immunity Environmental toxins Recurrent ovulation Infertile partner Obstructed menstrual flow
Principles of Management: n When the Problem is Pain – Use Medical Rx n When the Problem is Infertility – Use Surgical Rx n But it is a complex decision and individualisation of care is desirable n When there is no Problem – Use no Rx n Some patients require multidisciplinary care
Medical Therapy Options n Progestins n n n COC (best in continuous form) Provera or Norethisterone The Mirena IUS n Danazol & Gestrinone n Gn. RH agonists +/- Add Back Therapy n A question of side effects
Surgery for Endometriosis n Laparoscopy n n n Biopsy to confirm diagnosis is desirable Ablate superficial deposits taking care near bowel, bladder and ureters. Use bipolar diathermy There is evidence that excision may be marginally better Endometrioma – must remove cyst wall. Conserve as much ovary as possible. Extensive surgery with removal of entire pelvic peritoneum best done by advanced laparoscopic surgeon Hysterectomy +/- oophorectomy. Excise all visible lesions. Warn about recurrence risk
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