the modern management of endometriosis l.
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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?.

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what is it
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
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
Aetiology
  • Retrograde menstruation
  • tissue transplantation
  • peritoneal cell metaplasia
  • venous spread
  • lymphatic spread
  • immune failure
incidence
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 symptoms
endometriosis
Endometriosis

Diagnosis

  • laparoscopy
the natural progression
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
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
endometriosis12
Endometriosis

Management options 1

Diagnostic laparoscopy

Drugs

  • OCP
  • Provera
  • Danazol / Gestrinone
  • GNRH analogues

Surgery

  • Hysterectomy with BSO
endometriosis and fertility15
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)

endometriosis16
Endometriosis

Management option 2

  • Diagnostic laparoscopy proceeding to immediate corrective surgery; LASER and /or laparoscopic resection of diseased tissue
endometriosis17
Endometriosis

CO 2 LASER Vs Diathermy

  • depth of destruction
  • accuracy
  • collateral / unseen damage
  • placebo effect
  • cost
endometriosis treatment by co 2 laser
EndometriosisTreatment by CO2 LASER

Classification

I minimal

II mild

III moderate

IV severe

AFS

Pregnancies

72%

60%

50%

44%

Improved pain

89%

87%

85%

80%

Del Pozo 1997

women with pain
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
endometriosis on the caecum
Endometriosison the caecum

Endometriosis on the caecum

laser ablation of endometriosis
LASER ablation of endometriosis
  • endometriosis not cured by medication
  • surgery may cure the younger woman

Techniques

  • ablate
  • LUNA
  • resect peritoneum
  • ventrosuspension
requirements
Requirements
  • full RCOG accreditation
  • MAS accreditation
    • surgeon
    • preceptor
    • LASER certification
what to expect
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
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
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