Definition: Ectopic Endometrial Tissue True Incidence Unknown: ?

1-5% Does NOT Discriminate by Race Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction

Chronic Pelvic Pain, Dysmenorrhea (90%) Abnormal Uterine Bleeding Infertility (55% ) Deep Dyspareunia Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria, LBP, Hemoptysis

36 45 15%

> 45 3%

< 19 6%

19 25 24%

26 35 52%

Sampson: Retrograde Menstruation Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the Above

No Single Theory Explains All Cases of Endometriosis

Laparoscopy (Gold Standard) Laparotomy Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies Biopsy Preferable Over Visual Inspection

Endometriosis May Appear Brown Black (Powderburn) Clear (Atypical)

Recognize Goals: Pain Management Preservation / Restoration of Fertility Discuss with Patient: Disease may be Chronic and Not Curable Optimal Treatment Unproven or Nonexistent

IS TREATMENT ALWAYS REQUIRED? WHO NEEDS TREATMENT? DOES ANY TREATMENT REALLY WORK? DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?

ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE SPONtan REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSISPERSISTENCE, REGRESSION AND PROGRESSION

ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT LAPAROSCOPIC ABLATION OF VISIBLE ENDOmetriosis IN INFERTILE WOMEN IS ASSOCiate WITH SIGNIFICANTLY INCREASED FERTILITY RATES

NOT PRECISELY KNOWN2-5% 20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMEN BUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION 52% OF TEENAGES WITH Chronic Pelvic Pain SYNDROME

Single/nulliparous Early menarche Non oral contraception Non smoker shorter cycle/longer duration of flow Dysplastic naevus syndrome, melanoma

Adhesions distorsion Chronic salpingitis

Increased PGs

Cell mediated gamete inj Activated Increased macrophag prev. ABs

Defective folliculoge nisis LUFS

Altered Cytokines tubal motil Impaired oocyte pick up

Fertilizatio hyperprola n failure ctinaemia

Sperm Early spon Luteal phagocyto abortion phase sed deficency

NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Misc: Opoids, TCAs, SSRIs

Pseudopregnancy (Kistner) ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Treatments Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects

May be as Effective as GnRH-a for Pain Control MPA 10-30 mg/day, DP 150 mg Semi-Monthly May be Taken Long-Term Relatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Amenorrhea

PSYCO-PHYSICAL TREATMENTSACCUPUNCTURE, MASSAGE, RELAXATION, TENS EXERCISE ANTI-OESTROGEN DRUGS LAPAROSCOPY/ OPEN SURGERY

Weak Androgen Suppresses LH / FSH Causes Endometrial Regression, Atrophy Expensive Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes

Initially Stimulate FSH / LH Release Down-Regulates GnRH Receptors Pseudomenopause Long-Term Success Varies Expensive Use Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1 Year )

ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITE SHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASE RESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENT DOES NOT DEAL WITH ADHESIONS

NO TREAT DRUG THERA PY SURGE RY IVF

PREG RATE 44% 41%

n 235 418

65%
20

912
257

Endometriosis is a Common, Chronic Disease Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious Approach with Respect to Fertility Better Medical Therapies are Needed