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Prof. M.C.Bansal
        MBBS,MS,MICOG,FICOG
            Professor OBGY
       Ex-Principal & Controller
  Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
   Presence      of     active   functioning
    endometrial implants outside its normal
    place i.e uterine cavity
   Incidence:20-25% in reproductive age
    group
Implantation theory :
Sampson's pioneering work in 1922 attributed endometriosis
to reflux of menstrual endometrium through the fallopian
tubes. Occurrence of scar endometriosis following classical
caesarean section, hysterotomy, myomectomy and episiotomy
further supports this view.
Coelomic metaplasia theory :
Meyer and Ivanoff (1919) propounded that endometriosis
arises as a result of metaplastic changes in embryonic cell
rests of embryonic mesothelium. Hormonal stimulation of
Embryologically similar tissues to the Mullerian ducts.
 Metastatic theory :
Suggested by Halban et al. (1924) that embolization of
menstrual fragments through vascular or lymphatic
channels, explain its occurrence at less accessible sites
like the umbilicus, pelvic lymph nodes, ureter,
rectovaginal septum, bowel wall, and remote sites like
the lung, pleura, endocardium and the extremities.
Hormonal influence : The initial genesis of
endometriosis, its further development depends on the
presence of hormones, mainly oestrogen. Pregnancy
causes atrophy of endometriosis through high
progesterone level. Regression also follows oophorectomy
and irradiation. Endometriosis is rarely seen before
puberty and it regresses after menopause. Hormones with
antioestrogenic activity also suppress endometriosis and
are used therapeutically.
Immunological factor : The peritoneal fluid in
endometriosis shows the presence of macrophages and
natural killer (NK) cells. Impaired T cell and NK cell activity
and altered immunology.
Other factors : Genetic - familial tendency reported in
15% cases, multifactorial, vaginal or cervical atresia which
encourage retrograde spill. Prostaglandins.
Uterine :
Uterine : (50%)(50%)
 Adenomyosis
-Extra uterine :
  Ovary 30%
-- Ovaryperitoneum 10%
  Pelvic 30%
-- Pelvic peritoneum
  F. tube
-10%
  Vagina
 - F. tube
-Bladder & rectum
-- Vagina
  Pelvic colon
--Bladder & rectum
  Ligaments
 - Pelvic colon
 - Ligaments
endometriosis :
         (1) ovary
    (2) cul-de-sac
    (3) uterosacral
       ligaments
 (4) broad ligaments
  (5) fallopian tubes
 (6) uterovesical fold
 (7) round ligaments
     (8) vermiform
       appendix
        (9) vagina
   (10) rectovaginal
         septum
  (11) rectosigmoid
          colon
      (12) caecum
       (13) ileum
 (14) inguinal canals
(15) abdominal scars
      (16) ureters
 (17) urinary bladder
    (18) umbilicus
        (19) vulva
 (20) peripheral sites
- Pelvic
- Extra pelvic
Umbilicus.
Scars (Lap.).
Lungs & pleura.
Others.
Endometriosis
Early lesions appear papular and red vesicles are filled with
haemorrhagic fluid with surrounding flame-like lesions.
Over time, these vesicles change colour and endometriotic
areas appear as dark red, bluish or black cystic areas
adherent to the site. Scarring in the endometriosis makes it
puckered. Atypical lesions such as non-pigmented areas or
yellowish-white thick plaques have been noticed, which are
healed lesions. Powder burnt areas are the inactive and old
lesions seen scattered over the pelvic peritoneum.
Chocolate cysts of the ovaries represent the most important
manifestation of endometriosis. To the naked eye, the
chocolate cyst shows obvious thickening of tunica albuginea,
and vascular red adhesions are well marked on the
undersurface of the ovary. The inner surface of the cyst wall
is vascular and contains areas of dark brown tissue. The
chocolate cyst lies in the ovary and adherent to lateral pelvic
wall.
ADENOMYOSIS  GROSS SPECIMEN
MICROSCOPIC View of endometriosis interna (ADENOMYOSIS)s
2
1




    3



        HISTOPATHOLOGICAL IMAGES
                    OF
             1 ENDOMETRIOSIS,
         2 OVARIAN ENDOMETRIOMA,
        3 SECRETORY ENDOMETRIOSIS
On History
Common symptoms :
       Chronic pelvic pain, worsening dysmenorrhea,
acquired       dyspareunia,   infertility,   premenstrual
spotting, dyschezia.
Risk factors :
       First degree relative affected, short menstrual
cycles, long duration of menstrual flow, low parity,
infertility,   fair   complexioned,   reproductive   tract
Examination

       On bimanual pelvic examination, fixed retroverted uterus,

bilateral pelvic tenderness, fixed or enlarged ovaries and painful

uterosacral nodularity.

       Deeply infiltrating nodules are most reliably detected when

clinical examination is performed during menstruation.

Adenomyotic uterus is seldom > 12 weeks, soft, smooth & tender

in contrast to fibroid uterus. Isolated adenomyoma        can be

differentiated by presence of localised tenderness
Investigations
   Laparoscopy: Gold standard It should not be
    performed     within   3    months     of    hormonal
    treatment to prevent under diagnosis
   Ultrasound: Ultrasound has            a limited role,
    however the addition of colour doppler claims
    to increase the sensitivity to 91.8%, specificity
    of 91.3%
   MRI –useful
   Ca     125-Maybe           elevated     in     severe
Endometriosis
Histological Confirmation:

         Visual inspection is usually adequate but

histological confirmation of at least one lesion is

ideal.

         In cases of ovarian endometrioma >3 cm in

diameter     and   in   deeply   infiltrating   disease,

histology is a must to rule out malignancy.
Laparoscopy (Sensitivity : 97%, Specificity 95%)
Types of lesions on laparoscopy:
Powder burn or black lesions
White opacified peritoneum
Glandular excrescences
Flame like red lesions
Peritoneal pockets or windows
Clear vesicles
Yellow brown patches
Unexplained adherence of ovary to peritoneum of
  ovarian fossa
Encysted collection of thick chocolate coloured or
  tarry fluids
Adhesions to posterior lip of broad ligaments/other
Endometriosis
Endometriosis
LAPROSCOPIC IMAGES :
A  OLD ENDOMETRIOSIS (Blue/Grey)       B  OLD ENDOMETRIOSIS (Red)
C  OLD ENDOMETRIOSIS (Brown)       D  ACTIVE ENDOMETRIOSIS (Black)
Endometriosis
Endometriosis
Sonographic Features :

Endometritic cysts (oval or round)- capsulated, fine

 homogeneous,       uniform,     granular     echoes,

 anechoic, single or multiple, unilateral or bilateral

On Doppler: no vascularity within the mass

Ovarian adhesions to uterus

Free floating fimbria on sonosalpingography
   Several Proposed Schemes
   Revised AFS System: Most Often Used
   Ranges from Stage I (Minimal) to Stage IV (Severe)
   Staging Involves Location and Depth of Disease,
    Extent of Adhesions
Endometriosis
Revised American Fertility Society Classification of endometriosis 1985
 Patient's name     Age Date
 Stage I (Minimal) Score 1-5     Laparoscopy/Laparotomy/Photography
 Stage II (Mild) Score 6-15       Recommended treatment
 Stage III (Moderate) Score 16-40
 Stage IV (Severe) Score > 40
 Total                                Prognosis
Peritoneal endometriosis <1 cm 1-3 cm >3 cm
  Superficial                  1         2          4
  Deep                          2         4          6
Ovarian endometriosis <1 cm 1-3 cm >3 cm Right/Left side separate points
    Superficial             1       2          4
    Deep                     4       16        20
cul-de-sac obliteration Partial      Complete
                                 4           40
Ovarian adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
    Flimsy                 1                     2                  4
    Dense                  4                     8                  16
 Tubal adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
    Flimsy                  1                      2                 4
    Dense                  4                       8                16
   Age.
   Symptoms.
   Stage.
   Infertility
   Recognize Goals:
    –   Pain Management
    –   Preservation / Restoration of Fertility
   Discuss with Patient:
    –   Disease may be Chronic and Not
    Curable
    –   Optimal    Treatment     Unproven     or
    Nonexistent
   Management of Endometriosis must be ‘tailor

    made’   taking   into   account,   patients   profile,

    presenting symptoms, impact of the disease and

    effects of treatment on day to day life.
   Empirical treatment of pain symptoms without
    definitive    diagnosis       of        endometriosis,   a
    therapeutic trial of hormonal drug to reduce
    menstrual flow is appropriate.
   Medical Therapy for endometriosis can be used
    either as primary therapy or in conjunction with
    surgery      preoperatively        or     postoperatively-
    Sandwich Therapy
 How     effective   are   NSAIDS    in  treating
  endometriosis associated pain?
There is inconclusive evidence to show whether
  NSAIDS are effective in managing pain caused by
  endometriosis
Advantages:
Not operator dependent
Less expensive
No surgical/anesthetic risk
No post- op adhesion formation
Disadvantages:
Prolonged treatment
Gastric ulceration
Temporary relief
•   GnRH analogues: creates a pseudo menopausal
    state
•   Advantages:
•   Reduction in pelvic vascularity and inflammation
•   Reduction in size and activity of endometriotic
    implants
•   Reduction in ovarian cyst diameter
•   Reduction in cyst wall diameter
•   Disadvantages:
•   Hypoestrogenic state
•   Bone loss(can be controlled by add back regimen-
   Danazol: pseudomenopausal state
Inhibits ovarian steroidogenesis, decreases
    pulsatile GnRH release, decreases
    gonadotrophins-antioestrogenic,
    antiprogestogenic, androgenic effects
Dosage: 400mg/day
Efficacy: crude pregnancy rate 28-47%
 Progesterone:-     Pseudo pregnancy (Kristner’s
  Regime) state.
Acts by decidualisation and atrophy of the estrogen
  dependent endometriotic foci
Common progesterones : Medroxy progesterone
  acetate, norethesiterone, dydrogesterone,
DMPA - cost effective, readily available, 66%
  complete resolution
LNG-IUS(Mirena) reduces endometriosis associated
  pain(symptom control over 3 years)
Side effects : Irregular Bleeding, weight gain, fluid
  retention, breast tenderness, mood changes,
   Gestrinone: Androgenic, progestogenic and

    antiestrogenic

   Dosage: 1-25-2-5mg biweekly

   Side effects : similar to danazol
Combined OC Pills:

   To reduce the frequent prolonged bleeding not

    recommended in infertile endometriotic women.

   However COCs are the only effective prophylaxis

    in against endometriosis.
   RU 486: antiprogestogenic activity with minimal or
    no other endocrinologic effects
   Aromatase    Inhibitor:     Acts   on    the   diseased
    endometriotic implants to decrease local oestrogen
    production-to inhibit the growth of implants.
   Interferons: combination with GnRH have resulted
    in higher cumulative pregnancy rates and monthly
    fecundity rates
   SERMs: Selective antiestrogenic activity on the
    endometrium,      agonist   activity    on   bones   and
1997; Rice, 2002; Valle et al., 2003; Donnez et al., 2004;
             Crosignani et al., 2005; Schlaff et al., in press)

Agent            Dose         Route       Dosing frequency               Common side effects
Combined         30–35 μg     Oral        Daily (cyclic or continuous)   Irregular bleeding,
oral             ethinyl                                                 weight gain, bloating,
contraceptives   estradiol,                                              breast tension and
                 plus                                                    headache
                 progestin
Danazol          400–800      Oral        Daily (duration limited to     Androgenic/anabolic
                 mg                       6 months by side effects)      (weight gain, fluid
                                                                         retention, breast
                                                                         atrophy, acne, oily
                                                                         skin,
                                                                         hot flashes and
                                                                         hirsutism)
GnRH                                      (Duration limited to 6
agonists                                  months
                                          due to BMD effects)
Leuprolide       1mg/day      SC          daily                          Hypoestrogenic (hot
                              injection                                  flashes, vaginal
                                                                         dryness, emotional
                                                                         lability, loss of libido
                                                                         and BMD decline)
Leuprolide       3.75mg       IM          Monthly
depot            11.75mg      IM          Every 3 monthly
Agent           Dose      Route        Dosing frequency    Common side effects
Triptorelin     3mg       IM           Monthly
Triptorelin     11.25mg   IM           Every 3 monthly
depot
Goserelin       3.6mg     SC           Monthly
Buserelin       300-      Intranasal   Tds
                400µg
Naserelin       200-      Intranasal   Bd
                400µg
Progestins                                                 Irregular bleeding
                                                           bloating weight gain
                                                           and edema
Dydrogestero    60mg      Oral         12 days per cycle
ne
Gestrinone      2.5-5mg   Oral         Daily
Megestrel       40mg      Oral         Daily
acetate
Norethindrone   5mg       Oral         Daily
acetate
MPA             30mg      Oral         daily
DMPA-150        150mg     IM           Every 3 months
Indications:
Mild    Endometriosis      associated    with
 infertility
Endometrioma >4 cm in diameter
Endometriosis of rectovaginal septum or
 rectal wall
Failed Medical therapy
Intolerable side effects of medical therapy
Endometriosis     with      other   surgically
 correctable infertility factors
   Pre operative assessment: MRI or Ultrasound with

    or without IVP, Barium enema, sigmoidoscopy

   Preoperative and post-op medical management:

    GnRh-a like goserilin for 3 months preoperatively

    reduces the size and AFS score.

    Postoperative therapy gives longer period of

    remission.
   Primary operation is the best opportunity

   Best outcome by excision of the lesion

   Complete excision has lowest recurrence of

    19%

   Adhesions require excision rather than

    simple division
  Electrosurgical instruments are used for excision
   of endometriotic focii pelvic peritoneum, however
   the depth of dissection is unpredictable & hence
   damage to gut.
Sophisticated energy sources available are:
1. Carbon dioxide or Nd YAG laser: Allows
   vaporisation; excision; high cost
2. Harmonic scalpel: Ultrasound mechanical source,
   for cutting and coagulation
3. Argon beam: for widespread superficial lesion
4. Helica     thermal    coagulator:    effective  in
   vaporisation with risk of thermal damage.
Surgery when pain relief is the priority:
 Early stage disease: LUNA along with ablation of
  endometrial deposits improves outcome
 Moderate to severe disease: Removal of the entire
  lesion recommended
Endometrioma:
1. For       large     unilateral     endometrioma-
    salpingoopherectomy of the affected side;
2. Bilateral large endometrioma: <40years: ovarian
    tissue to be conserved as far as possible
3. Insufficient evidence to justify use of pre op or
    post op hormones
4. HRT        recommendation        after     bilateral
    salpingooherectomy is controversial
Surgery when infertility is the priority
   Early stage disease: Laparoscopic excision or
    ablation with adhesiolysis
   Moderate to severe endometriosis: role of surgery
    is   uncertain(overactive    excision   may   reduce
    fertility)
   Endometrioma:     laparosopic    cystectomy   better
    than drainage and coagulation.
Post op hormonal treatment has no beneficial effect
    on pregnancy rates after surgery
Tubal flushing improves pregnancy rates.
Endometriosis
   Treatment with IUI improves fertility in minimal to
    mild endometriosis
   IVF appropriate especially when tubal function is
    compromised, if there is male factor infertility
    and/or other treatments have failed.
   Treatment with GnRH agonists for 3-6months
    before IVF increases the rate of clinical
    pregnancies
   Laparoscopic ovarian cystectomy is recommended
    for endometriomas >4cm in diameter.

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Endometriosis

  • 1. Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
  • 2. Presence of active functioning endometrial implants outside its normal place i.e uterine cavity  Incidence:20-25% in reproductive age group
  • 3. Implantation theory : Sampson's pioneering work in 1922 attributed endometriosis to reflux of menstrual endometrium through the fallopian tubes. Occurrence of scar endometriosis following classical caesarean section, hysterotomy, myomectomy and episiotomy further supports this view. Coelomic metaplasia theory : Meyer and Ivanoff (1919) propounded that endometriosis arises as a result of metaplastic changes in embryonic cell rests of embryonic mesothelium. Hormonal stimulation of Embryologically similar tissues to the Mullerian ducts. Metastatic theory : Suggested by Halban et al. (1924) that embolization of menstrual fragments through vascular or lymphatic channels, explain its occurrence at less accessible sites like the umbilicus, pelvic lymph nodes, ureter, rectovaginal septum, bowel wall, and remote sites like the lung, pleura, endocardium and the extremities.
  • 4. Hormonal influence : The initial genesis of endometriosis, its further development depends on the presence of hormones, mainly oestrogen. Pregnancy causes atrophy of endometriosis through high progesterone level. Regression also follows oophorectomy and irradiation. Endometriosis is rarely seen before puberty and it regresses after menopause. Hormones with antioestrogenic activity also suppress endometriosis and are used therapeutically. Immunological factor : The peritoneal fluid in endometriosis shows the presence of macrophages and natural killer (NK) cells. Impaired T cell and NK cell activity and altered immunology. Other factors : Genetic - familial tendency reported in 15% cases, multifactorial, vaginal or cervical atresia which encourage retrograde spill. Prostaglandins.
  • 5. Uterine : Uterine : (50%)(50%) Adenomyosis -Extra uterine : Ovary 30% -- Ovaryperitoneum 10% Pelvic 30% -- Pelvic peritoneum F. tube -10% Vagina - F. tube -Bladder & rectum -- Vagina Pelvic colon --Bladder & rectum Ligaments - Pelvic colon - Ligaments
  • 6. endometriosis : (1) ovary (2) cul-de-sac (3) uterosacral ligaments (4) broad ligaments (5) fallopian tubes (6) uterovesical fold (7) round ligaments (8) vermiform appendix (9) vagina (10) rectovaginal septum (11) rectosigmoid colon (12) caecum (13) ileum (14) inguinal canals (15) abdominal scars (16) ureters (17) urinary bladder (18) umbilicus (19) vulva (20) peripheral sites
  • 7. - Pelvic - Extra pelvic Umbilicus. Scars (Lap.). Lungs & pleura. Others.
  • 9. Early lesions appear papular and red vesicles are filled with haemorrhagic fluid with surrounding flame-like lesions. Over time, these vesicles change colour and endometriotic areas appear as dark red, bluish or black cystic areas adherent to the site. Scarring in the endometriosis makes it puckered. Atypical lesions such as non-pigmented areas or yellowish-white thick plaques have been noticed, which are healed lesions. Powder burnt areas are the inactive and old lesions seen scattered over the pelvic peritoneum. Chocolate cysts of the ovaries represent the most important manifestation of endometriosis. To the naked eye, the chocolate cyst shows obvious thickening of tunica albuginea, and vascular red adhesions are well marked on the undersurface of the ovary. The inner surface of the cyst wall is vascular and contains areas of dark brown tissue. The chocolate cyst lies in the ovary and adherent to lateral pelvic wall.
  • 11. MICROSCOPIC View of endometriosis interna (ADENOMYOSIS)s
  • 12. 2 1 3 HISTOPATHOLOGICAL IMAGES OF 1 ENDOMETRIOSIS, 2 OVARIAN ENDOMETRIOMA, 3 SECRETORY ENDOMETRIOSIS
  • 13. On History Common symptoms : Chronic pelvic pain, worsening dysmenorrhea, acquired dyspareunia, infertility, premenstrual spotting, dyschezia. Risk factors : First degree relative affected, short menstrual cycles, long duration of menstrual flow, low parity, infertility, fair complexioned, reproductive tract
  • 14. Examination On bimanual pelvic examination, fixed retroverted uterus, bilateral pelvic tenderness, fixed or enlarged ovaries and painful uterosacral nodularity. Deeply infiltrating nodules are most reliably detected when clinical examination is performed during menstruation. Adenomyotic uterus is seldom > 12 weeks, soft, smooth & tender in contrast to fibroid uterus. Isolated adenomyoma can be differentiated by presence of localised tenderness
  • 15. Investigations  Laparoscopy: Gold standard It should not be performed within 3 months of hormonal treatment to prevent under diagnosis  Ultrasound: Ultrasound has a limited role, however the addition of colour doppler claims to increase the sensitivity to 91.8%, specificity of 91.3%  MRI –useful  Ca 125-Maybe elevated in severe
  • 17. Histological Confirmation: Visual inspection is usually adequate but histological confirmation of at least one lesion is ideal. In cases of ovarian endometrioma >3 cm in diameter and in deeply infiltrating disease, histology is a must to rule out malignancy.
  • 18. Laparoscopy (Sensitivity : 97%, Specificity 95%) Types of lesions on laparoscopy: Powder burn or black lesions White opacified peritoneum Glandular excrescences Flame like red lesions Peritoneal pockets or windows Clear vesicles Yellow brown patches Unexplained adherence of ovary to peritoneum of ovarian fossa Encysted collection of thick chocolate coloured or tarry fluids Adhesions to posterior lip of broad ligaments/other
  • 21. LAPROSCOPIC IMAGES : A  OLD ENDOMETRIOSIS (Blue/Grey) B  OLD ENDOMETRIOSIS (Red) C  OLD ENDOMETRIOSIS (Brown) D  ACTIVE ENDOMETRIOSIS (Black)
  • 24. Sonographic Features : Endometritic cysts (oval or round)- capsulated, fine homogeneous, uniform, granular echoes, anechoic, single or multiple, unilateral or bilateral On Doppler: no vascularity within the mass Ovarian adhesions to uterus Free floating fimbria on sonosalpingography
  • 25. Several Proposed Schemes  Revised AFS System: Most Often Used  Ranges from Stage I (Minimal) to Stage IV (Severe)  Staging Involves Location and Depth of Disease, Extent of Adhesions
  • 27. Revised American Fertility Society Classification of endometriosis 1985 Patient's name Age Date Stage I (Minimal) Score 1-5 Laparoscopy/Laparotomy/Photography Stage II (Mild) Score 6-15 Recommended treatment Stage III (Moderate) Score 16-40 Stage IV (Severe) Score > 40 Total Prognosis Peritoneal endometriosis <1 cm 1-3 cm >3 cm Superficial 1 2 4 Deep 2 4 6 Ovarian endometriosis <1 cm 1-3 cm >3 cm Right/Left side separate points Superficial 1 2 4 Deep 4 16 20 cul-de-sac obliteration Partial Complete 4 40 Ovarian adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side separate points Flimsy 1 2 4 Dense 4 8 16 Tubal adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side separate points Flimsy 1 2 4 Dense 4 8 16
  • 28. Age.  Symptoms.  Stage.  Infertility
  • 29. Recognize Goals: – Pain Management – Preservation / Restoration of Fertility  Discuss with Patient: – Disease may be Chronic and Not Curable – Optimal Treatment Unproven or Nonexistent
  • 30. Management of Endometriosis must be ‘tailor made’ taking into account, patients profile, presenting symptoms, impact of the disease and effects of treatment on day to day life.
  • 31. Empirical treatment of pain symptoms without definitive diagnosis of endometriosis, a therapeutic trial of hormonal drug to reduce menstrual flow is appropriate.  Medical Therapy for endometriosis can be used either as primary therapy or in conjunction with surgery preoperatively or postoperatively- Sandwich Therapy
  • 32.  How effective are NSAIDS in treating endometriosis associated pain? There is inconclusive evidence to show whether NSAIDS are effective in managing pain caused by endometriosis Advantages: Not operator dependent Less expensive No surgical/anesthetic risk No post- op adhesion formation Disadvantages: Prolonged treatment Gastric ulceration Temporary relief
  • 33. GnRH analogues: creates a pseudo menopausal state • Advantages: • Reduction in pelvic vascularity and inflammation • Reduction in size and activity of endometriotic implants • Reduction in ovarian cyst diameter • Reduction in cyst wall diameter • Disadvantages: • Hypoestrogenic state • Bone loss(can be controlled by add back regimen-
  • 34. Danazol: pseudomenopausal state Inhibits ovarian steroidogenesis, decreases pulsatile GnRH release, decreases gonadotrophins-antioestrogenic, antiprogestogenic, androgenic effects Dosage: 400mg/day Efficacy: crude pregnancy rate 28-47%
  • 35.  Progesterone:- Pseudo pregnancy (Kristner’s Regime) state. Acts by decidualisation and atrophy of the estrogen dependent endometriotic foci Common progesterones : Medroxy progesterone acetate, norethesiterone, dydrogesterone, DMPA - cost effective, readily available, 66% complete resolution LNG-IUS(Mirena) reduces endometriosis associated pain(symptom control over 3 years) Side effects : Irregular Bleeding, weight gain, fluid retention, breast tenderness, mood changes,
  • 36. Gestrinone: Androgenic, progestogenic and antiestrogenic  Dosage: 1-25-2-5mg biweekly  Side effects : similar to danazol
  • 37. Combined OC Pills:  To reduce the frequent prolonged bleeding not recommended in infertile endometriotic women.  However COCs are the only effective prophylaxis in against endometriosis.
  • 38. RU 486: antiprogestogenic activity with minimal or no other endocrinologic effects  Aromatase Inhibitor: Acts on the diseased endometriotic implants to decrease local oestrogen production-to inhibit the growth of implants.  Interferons: combination with GnRH have resulted in higher cumulative pregnancy rates and monthly fecundity rates  SERMs: Selective antiestrogenic activity on the endometrium, agonist activity on bones and
  • 39. 1997; Rice, 2002; Valle et al., 2003; Donnez et al., 2004; Crosignani et al., 2005; Schlaff et al., in press) Agent Dose Route Dosing frequency Common side effects Combined 30–35 μg Oral Daily (cyclic or continuous) Irregular bleeding, oral ethinyl weight gain, bloating, contraceptives estradiol, breast tension and plus headache progestin Danazol 400–800 Oral Daily (duration limited to Androgenic/anabolic mg 6 months by side effects) (weight gain, fluid retention, breast atrophy, acne, oily skin, hot flashes and hirsutism) GnRH (Duration limited to 6 agonists months due to BMD effects) Leuprolide 1mg/day SC daily Hypoestrogenic (hot injection flashes, vaginal dryness, emotional lability, loss of libido and BMD decline) Leuprolide 3.75mg IM Monthly depot 11.75mg IM Every 3 monthly
  • 40. Agent Dose Route Dosing frequency Common side effects Triptorelin 3mg IM Monthly Triptorelin 11.25mg IM Every 3 monthly depot Goserelin 3.6mg SC Monthly Buserelin 300- Intranasal Tds 400µg Naserelin 200- Intranasal Bd 400µg Progestins Irregular bleeding bloating weight gain and edema Dydrogestero 60mg Oral 12 days per cycle ne Gestrinone 2.5-5mg Oral Daily Megestrel 40mg Oral Daily acetate Norethindrone 5mg Oral Daily acetate MPA 30mg Oral daily DMPA-150 150mg IM Every 3 months
  • 41. Indications: Mild Endometriosis associated with infertility Endometrioma >4 cm in diameter Endometriosis of rectovaginal septum or rectal wall Failed Medical therapy Intolerable side effects of medical therapy Endometriosis with other surgically correctable infertility factors
  • 42. Pre operative assessment: MRI or Ultrasound with or without IVP, Barium enema, sigmoidoscopy  Preoperative and post-op medical management: GnRh-a like goserilin for 3 months preoperatively reduces the size and AFS score. Postoperative therapy gives longer period of remission.
  • 43. Primary operation is the best opportunity  Best outcome by excision of the lesion  Complete excision has lowest recurrence of 19%  Adhesions require excision rather than simple division
  • 44.  Electrosurgical instruments are used for excision of endometriotic focii pelvic peritoneum, however the depth of dissection is unpredictable & hence damage to gut. Sophisticated energy sources available are: 1. Carbon dioxide or Nd YAG laser: Allows vaporisation; excision; high cost 2. Harmonic scalpel: Ultrasound mechanical source, for cutting and coagulation 3. Argon beam: for widespread superficial lesion 4. Helica thermal coagulator: effective in vaporisation with risk of thermal damage.
  • 45. Surgery when pain relief is the priority:  Early stage disease: LUNA along with ablation of endometrial deposits improves outcome  Moderate to severe disease: Removal of the entire lesion recommended Endometrioma: 1. For large unilateral endometrioma- salpingoopherectomy of the affected side; 2. Bilateral large endometrioma: <40years: ovarian tissue to be conserved as far as possible 3. Insufficient evidence to justify use of pre op or post op hormones 4. HRT recommendation after bilateral salpingooherectomy is controversial
  • 46. Surgery when infertility is the priority  Early stage disease: Laparoscopic excision or ablation with adhesiolysis  Moderate to severe endometriosis: role of surgery is uncertain(overactive excision may reduce fertility)  Endometrioma: laparosopic cystectomy better than drainage and coagulation. Post op hormonal treatment has no beneficial effect on pregnancy rates after surgery Tubal flushing improves pregnancy rates.
  • 48. Treatment with IUI improves fertility in minimal to mild endometriosis  IVF appropriate especially when tubal function is compromised, if there is male factor infertility and/or other treatments have failed.  Treatment with GnRH agonists for 3-6months before IVF increases the rate of clinical pregnancies  Laparoscopic ovarian cystectomy is recommended for endometriomas >4cm in diameter.