ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE
Endometriosis: The Pain That Keeps on Giving
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”
5. ENDOMETRIOSIS: THE BITTER TRUTH
Prevalence rate – no: body knows !!
35%–50% in women experiencing pain or infertility
Elusive Pathogenesis
Healthcare costs are estimated to exceed
$70 billion every year- underestimated
Acien P, Velasco I. Endometriosis: A Disease That Remains Enigmatic. ISRN Obstetrics and
Gynecology. 2013; http://dx.doi.org/10.1155/2013/242149
Donnez J. Endometriosis: enigmatic in the pathogenesis and controversial in its therapy. (Fertil
Steril. 2012;98:509–10 …Caring hearts, healing hands
6. Remains Controversial Despite…..
Existence of a journal and various regular
international congresses & dedicated forums / societies
specifically to the disease
Current scientific and technological advances
Publication of a large number of manuscripts
Acien P, Velasco I. Endometriosis: A Disease That Remains Enigmatic. ISRN Obstetrics and Gynecology.
2013; http://dx.doi.org/10.1155/2013/242149
Donnez J. Endometriosis: enigmatic in the pathogenesis and controversial in its therapy. (Fertil Steril.
2012;98:509–10 …Caring hearts, healing hands
9. • Age: common in reproductive period
• True Incidence Unknown: ?
• Does NOT Discriminate by Race.
• Histology: Endometrial Glands with Stroma
+/- Inflammatory Reaction.
• Hereditary (↑↑ among sisters).
Epidemiology
10. Delay to Diagnosis of
8 to 10 years is the RULE
Delay of
• 10 years in Germany and Austria
• 8 years in the UK and Spain,
• 7 years in Norway, Italy
• 4–5 years in Ireland and Belgium
INDIA--- ?
15. RISK FACTORS (Odukoya & Cooke, 1996)
I- ASSOCIATED:
First or second degree
relation.
Menstrual cycle < 27 days.
Menstrual duration > 7 days.
Genital outflow obstruction.
II- INCONCLUSIVE:
Obesity,
Exercise,
Age at menarche,
uterine retroversion.
III- NOT ASSOCIATED:
Age
Race
Social class
duration of marriage
ICUD
Miscarriage
16. Predisposing Factors
1. Hyperoestrinism:
a) Fibroid & metropathia hemorrhagica.
b) Delayed marriage, infertility.
c) Oestrogen secreting tumours of the ovary e.g. granulosa
& theca cell tumours, or with prolonged oestrogen therapy.
2. Cervical Stenosis.
3. Insufflation ?
4. Curettage ?
20. DONNEZ ET AL (2003)
• Red lesions = Early endometriosis
• Black lesions = Advanced endometriosis
• White = Lesions are believed to be
- Healed endometriosis or
- Quiescent or latent lesions.
21. ASRM classification (1996)
• The only difference between the 1985 rAFS classification &
1996 ASRM classification is that the latter includes
information on the morphologic appearance of the disease.
• Red: red, red-pink & clear lesions
• White: white, yellow-brown, peritoneal defects, subovarian
adhesion
• Black: black & blue lesions.
• Denote percent of total described as
• R ….%, W ….% and B ….%.
• Total should equal 100%.
22. CLASSIFICATION
• The revised American Fertility Society (rAFS)
(1985)was produced to standardize the
documentation of findings in patients who
have pelvic pain & endometriosis.
• Staging Involves:
• 1. Location
• 2. Depth of Disease,
• 3. Extent of Adhesions.
23. REVISED AFS (1985)
• Stage I (minimal) 1 – 5.
• Stage II (mild) 6 – 15.
• Stage III (moderate) 16 – 40.
• Stage IV (severe) > 40.
25. IN WOMEN OF REPRODUCTIVE AGE WITH
NON-GYNAECOLOGICAL CYCLICAL SYMPTOMS
• Dyschezia
• Dysuria
• Haematuria
• Rectal bleeding
• Shoulder pain.
26. Pelvic examination may reveal:
1. Pelvic tenderness.
2. Fixed retroverted uterus.
3. Nodularity of the Douglas pouch and
uterosacral ligaments.
4. Ovaries may be enlarged and tender .
5.Ovarian cyst may be detected.
Signs
27. • It should include both-
• Per Abdomen
• Per Speculum
• Per Vaginum
• Highest predictive value
• -- Menstruation
In all women suspected of
endometriosis
28. For adolescents and/or women without
previous sexual intercourse
• Rectal examination can be helpful for the
diagnosis of endometriosis.
• Only after Counselling and Verbal
Consent
29. Suspect Deep Endometriosis
• Women with (painful) induration and/or
nodules of the Rectovaginal wall found
during clinical examination or
• Visible vaginal nodules in the posterior
vaginal fornix
34. Magnetic Resonance Imaging
????
• Clinicians should be aware that the
usefulness of magnetic resonance
imaging (MRI)
to diagnose Peritoneal Endometriosis
is not well established
35. Biomarkers ????
Clinicians are recommended not to use
biomarkers to diagnose endometriosis in
• endometrial tissue,
• menstrual or uterine fluids
• and/or immunological biomarkers, including
CA-125, in plasma, urine or serum
37. Treatment (Rationale)
• Recognize Goals:
– Pain Management
– Preservation / Restoration of Fertility
• Discuss with Patient:
– Disease may be Chronic and Not Curable
– Optimal Treatment Unproven or Nonexistent
38. When is Medical Treatment
Required ?
• First line treatment with chocolate cyst?
• First line treatment with superficial / deep
nodules?
• Role before surgery ?
• After surgery to prevent recurrence ?
• When surgery is not possible or refused ?
Full of
controversies
40. Limitations of surgery
Skill / Recurrence
LONG LEARNING CURVE
High risk of recurrence after surgery
25 % recurrence after 2 years
50 % at 5 years
40 – 80 % women have PAIN again
within 2 years of surgery
41. Endometriosis & IVF
• The presence of endometriosis does
not generally impair the results of
IVF but it increases the risk of
infection.
• It is preferable not to cauterize
ovarian endometrium if IVF or ICSI is
indicated for fear of destruction of
ovarian tissues.
43. • Endometriosis is a mystery for
gynaecologists as it requires decision
making at every stage by the Doctor and the
patient.
• Endometriosis still stand as one of the
most-investigated disorders in gynecology.
SO is one of the highest priorities for
research
TAKE HOME MESSAGE