1 / 43

Update on Endometriosis Grampians Medicare Local 2 nd September, BHS

Update on Endometriosis Grampians Medicare Local 2 nd September, BHS. Russell Dalton Ballarat IVF Ballarat Endometriosis Clinic Obstetrics & Gynaecology Ballarat. The A im today.

Download Presentation

Update on Endometriosis Grampians Medicare Local 2 nd September, BHS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Update on EndometriosisGrampians Medicare Local2nd September, BHS Russell Dalton Ballarat IVF Ballarat Endometriosis Clinic Obstetrics & Gynaecology Ballarat

  2. The Aim today.. • Young women with possible endometriosis • Older women with suspected endometriosis • What to look for. • Treatment options & rationale for these • Aromatase inhibitors • The role of endometriosis in subfertility • The future of endometriosis treatment

  3. Endometriosis • Common condition 2-10 % of women • Presents: varying stages of reproductive life • Later presentation , tends to be more severe • Ectopic endometrium, • Pelvis, mainly in dependent areas. • Peritoneal cavity • Rarely other locations, • Rarely in oestrogenised males

  4. Endometriosis images • Micro

  5. Endometriosis:what happens? • Theories: • In situ development: coelomic metaplasia • Induction theory: differentiation of mesenchymal cells • Transplantation Theory: implantation of retrograde menstruation • Need a process of: • Survival of detached cells, attachment & invasion of peritoneum, • Proliferation & Neo-vascularization

  6. Why does it happen? • Endometriosis cells : marked resistance to Apoptosis • Role of CD 1347 cell membrane glycoprotein controlling cell migration & Cadherin lack ( Inhibits cell spread) • Matrix metallo-proteinases ( disrupt intercellular bonds) • Vascular &epithelial growth factors, cytokines, growth factors (VEGF) released by abnormally functioning leucocytes • Genetics: Clear familial association • 6-7x more prevalent in first degree relatives of affected women • ?disease of Epigenetic origins increasing evidence

  7. Endometriosis- The cost • Major burden on Health services • Annual Healthcare costs (US) :$2801 per patient • Loss of productivity (US) $1023 per patient • Significant adverse influence on QOL & rates of depression. • Contributor in 50% of couples with infertility

  8. Endometriosis-Presenting symptoms • Pelvic pain • Dysmenorrhea • Pain related to function of pelvic organs • Bloating • Psychological sequelae. • Subfertility / Infertility

  9. Endometriosis in Young women • Difficult clinical challenge. • Often generalized Gynae symptoms: • Pain, irregular bleeding, bloating, headaches, lethargy • What is normal? • Other influences on symptoms: • puberty, relationships etc • Is something else going on ?

  10. Endo in Young women • Clinical assessment: • Appropriate history including sexual history • NB Ballarat 40% higher teen mum rate than Vic average) • More specifically related to menstrual cycle, more likely to be endometriosis • Physical examination:limited due to age etc • Ultrasound : TA Sensitivity -limited • Exclude other causes – sepsis, IBD other bowel pathology,

  11. Endo in Younger women.Treatment Principles • Our Goal: • Minimize symptoms & side effects • Stay out of Emergency Department • Stay off codeine/Narcotic based analgesia • Have High QOL / emotional well being scores • Suppression of ovulation

  12. Ovulation Suppression • via continuous hormonal regimen • Reduces endometriosis activity • Controls cyclical, dysmenorrhea. • Options: • OCP, Depo, Nuva Ring. • Only standard preparations apart from GnRHanalogues • 2 Microlut/day • Need to use combinations of other medications if alternatives needed

  13. Endometriosis & Mirena • Shown to reduce dysmenorrhea but not dyspareunia • Doesn’t suppress ovulation • Need equivalent of 50mcg levonorgestrol/day • So : Mirena(20 + microlut 30) Often used in conjunction with laparoscopy • Difficult insertion in nulliparous • Additional benefit with associated Adenomyosis

  14. Endometriosis & Implanon • Observational study & small RCT • improvement of symptoms • Dysmenorrhea • Dyspareunia • Non menstrual pelvic pain • Similar to Depo for 12/12 ( Ovulation suppression) • ? Double dose Implanon

  15. Endo in Younger Women • Treatment of pain: • Analgesics • NSAIDS: best for Gynaecological pain. Prob best for endo • Paracetamol /Codeine /doxylamine • Exercise: Consistent reduction in pain scores • Diet & Vitamins • Vegetarian diet, Increased dairy intake • Fich oilB1, B 6 : • Vitamin D starting 5 days pre menstrually

  16. Endo in younger women:Pyschological support • CBT & Psychology. • General support: Clinician support, encourage compliance& continuous hormonal regimen. • Endometriosis Nurse: email, text &phone support • Allay concerns regarding side effects • Often treatment regimens require changing

  17. Endometriosis in younger women • When to perform a laparoscopy: • Complex symptoms • Poor response. • Ultrasound abnormalities. • Abnormalities on examination (can be limited) • Findings are often mild endometriosis, • Occasional localised disease able to be excised. • Small biopsy required to confirm diagnosis

  18. Miliary pattern Endometriosis • Insert pic

  19. Post Laparoscopy Management • Change of OCP: • more progestagenic • Norinyl 1 +/- additional norethisterone • Other OCP • ZoladexGnRH analogues • ? Aromatase inhibitors + OCP / progestagens • Nurse/ Clinician support.

  20. Endometriosis on older women ( 30yrs +) • CAN present as younger women do. • BUT usually more extensive/infiltrating • Elucidate localizing symptoms. • Ipsilateral dysmenorrhea & dyspareunia • Menstrual related dyschezia & sacral pain. • Bowel dysfunction • Generalized intermenstrual pelvic pain • Intermenstrual bleeding &menorrhagia • (?associated adenomyosis)

  21. Endo in older women ( 30yrs +) • What to look for on examination. • Localized tenderness in the posterior & lateral fornix • Positioning of the cervix • Deviation laterally • Nodularity /crimping of the vagina • Mobility & tenderness of the uterus • ?associated Adenomyosis

  22. Endometriosis in the posterior fornix

  23. Endo in older women-Ultrasound Assessment • Look at pelvic organs, fibroids, cysts/endometriomata, endometrial, myometrial pathology • AND parametrial & pelvic side wall characteristics • Increased & discordant uterosacral & parametrial echoes • Pouch of Douglas peritoneal thickening • Rectosigmoid- cervicouterine tethering • Rectovaginal space tethering

  24. CA 125 • CA 125 cell surface antigen from derivatives of coelomicepith. • Not a sensitive test, but often elevated, esp with endometriomas & more advanced disease • Other causes: menstruation, ovulation, Infection, fibroids, pregnancy, Ovarian cancer • Older the patient, more careful consideration of elevated level

  25. Management • Same principles as for younger women • Ovulation suppression • Stable hormonal environment • Analgesia • May need combination therapy • Consider earlier surgical intervention for associated abnormalities on clinical/ultrasound examination

  26. Endometrioma • Invagination of ovarian serosal endometriosis • - Damage ovaries • 80% associated with Pouch Endometriosis. • Surgical treatment requires care • Diff Diagnosis: Functional cyst, Dermoid. • Confirm with trial of OCP suppression

  27. Endometrioma • Add US & lapy image

  28. Bowel involvementusually bowel symptoms • Show lapy image

  29. Bowel Involvement • Initial planning laparoscopy: EUA, Images • Combined Gynae & Colorectal surgical approach. • Often Zoladex to reduce volume & inflammation • Bowel prep, preop planning(nurse), consult x 2 • Strict systematic approach to surgery. • Disc excision,or segmental bowel resection, often “ultralow” anastamosis • Careful resection back to normal tissue

  30. Complex endometriosis surgery

  31. Endometriosis & Aromatase • Converts Androgen to Oestrogen • Aromatase inappropriately expressed in eutopic endometrium & endometroisis High levels of expression in endometriomas. Facilitates local production of Oestrogen. >> stimulates proliferation of endometriosis deposits

  32. New Agent for Endometriosis • Aromatase inhibitors: • Anastrazole, Letrozole. (off label) • For those with refractory pain& minimal visible disease. • Add to current regimens • In combination with OCP or progestagen • Can be used in conjunction with Zoladex • Significant reduction in pain scores • Note: Bone loss Risk : Ca. Vit D supps .

  33. Subfertility:What is normal Conception rate? • Age influenced. • Life plans • Other fertility factors • Male factor • Lifestyle Obesity, Smoking, • Ovulation. • 12 month definition is fairly blunt instrument

  34. 25-30 yr old Healthy couple fecundability

  35. Endometriosis & subfertility • Strong association. 40 -50% with subfertility • (OGB :70%of fertility pts have endometriosis) • Often have minimal pain. • Many couples have a number of contributing factors • Need to optimize each factor. • Older the woman more important to correct contributing factors

  36. Endometriosis contributes to subfertility • Distortion of pelvic structures • Ovarian damage ( reduced reserve) • Abnormal Eutopic endometrium • Impaired fertilization (inflammatory mediators) • Poor oocyte quality • -Better pregnancy with normal donor eggs • -Worse rates from endometriosis egg donors

  37. Outcomes of Interventions:Natural attempts • 200 couples planning pregnancy • 60% of pregnancies occur in • 3 cycles of Rx • 70% in 5 cycles of treatment • Any intervention has similar shaped curve

  38. Fertility Treatment options • Expectant • Younger woman, couple desires • Surgery • Excision deposits, tubal patency, endometrial biopsy • Ovulation induction with IUI • Letrozole, FSH, Clomiphene • IVF. • Fertilization outside pelvis, embryo selection

  39. Effects of Endometriosis on treatment outcomes • Subfertile couples with endometriosis have lower pregnancy rates. • Compared to male factor, tubal factor, idiopathic • Due to: • functional, proteomic abnormalities in Eutopic endometrium • Ongoing adverse effects of endometriosis on pelvic environment. Via inflammatory mediators • Reduced oocyte quality • Adverse effect correlates with severity, and age

  40. Results of treatment on Endometriosis related fertility • Complex interpretation of influence of each component. • Surgical studies • Heterogeneous disease pattern • Inter patient variation & variable surgical techniques. • Different thresholds for intervention • Often multifactorial infertility • Age variations

  41. Overall, we can say.. • Natural conception can still be pursued • Ovulation induction + IUI improves pregnancy rates • 2-3 cycles only • Excision surgery for mild-moderate reduces time to pregnancy. • Improves implantation rates • Improves natural conception rates. • Treatment of Endometriomasreduces oocyte yield, but increases natural conception rates & reduces infection rates from IVF, • “Long down regulation” with Zoladex prior to IVF improves pregnancy rates in women with severe endometriosis

  42. The Future of Endometriosis treatment • Immunologically based Therapy influencing Leucocyte function Chemokine receptor 1 antagonist ( CCR-1) • Anti Nerve growth factor ( ANGF) • Endometriosis as an epigenetic disease • Hypermethylation of promoter genes cause aberrant expression esp of aromatase & cadherin 1 • Histone DeaCetylase Inhibitors ( HDACI s) may reverse hypermethylation : (Valproate)

  43. Summary • Endometriosis is a common condition. • Young women: mild , use hormonal therapy • Older women; look for localizing symptoms • Ovulation suppression –range of options • Significant influence on fertility • Surgical management can be technically complex requiring multidisciplinary approach.

More Related