ENDOMETRIOSIS

WHAT IS THE GENERAL

PRACTICE APPROACH?
FIRST – A FEW QUESTIONS!
IS TREATMENT ALWAYS REQUIRED?
WHO NEEDS TREATMENT?
DOES ANY TREATMENT REALLY WORK?
DOES TREATMENT IN YOUNG WOMEN
PREVENT INFERTILITY AND
PROGRESSION?
I DON’T HAVE THE ANSWERS
ENDOMETRIOSIS PROGRESSES IN
MOST CASES OF MODERATE AND
SEVERE DISEASE
SPON REGRESSION CAN OCCUR IN UP
TO 58% OF MILDER CASES
NATURAL HISTORY IS STILL
UNCHARTED TO A LARGE EXTENT
HOWEVER----
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
ENDOMETRIOSIS—PERSISTENCE,
REGRESSION AND PROGRESSION
AND ALSO---------
ENDOMETRIOSIS MAY OCCUR IN THE EARLY
MENOPAUSE, USUALLY IN ASSOCIATION
WITH HRT
LAPAROSCOPIC ABLATION OF VISIBLE ENDO
IN INFERTILE WOMEN IS ASSOC WITH
SIGNIFICANTLY INCREASED FERTILITY
RATES
THERE IS NO DATA REGARDING EARLY
INTERVENTION WRT PREVENTION
PREVALENCE
NOT PRECISELY KNOWN—2-5%
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 CPP SYNDROME
Familial association
Relative Risk to siblings 2.3 overall

Relative Risk to sibs if severe endo 15

Risk factors
Single/nulliparous
Early menarche
Non oral contraception
Non smoker shorter cycle/longer
duration of flow
Dysplastic naevus syndrome, melanoma
symptoms
90% severe dysmenorrohoea
70% chronic pelvic pain
75% dyspareunia
55% infertility
Infertility mechanisms

Adhesions Increased Cell Defective

distorsion PGs mediated folliculoge
gamete inj nisis
Chronic Activated Increased LUFFS
salpingitis macrophag prev. ABs
Altered Cytokines Fertilizatio hyperprola
tubal motil n failure ctinaemia
Impaired Sperm Early spon Luteal
oocyte phagocyto abortion phase
pick up sed deficency
Treatment of pain
NSAIDS: all significantly better than
placebo, studies vary which one is best
Naproxen >mefanemic acid>aspirin
Naproxen=ibuprofen
Naproxen only drug with significant SEs
treatment of menstrual pain
Treatment level of evidence
Simple analgesics 1
Herbal remedies 1
alcohol 2
Antidepressants/anxiolytics 2
OCPs 1
NSAIDS 3
ENDOMETRIOSIS PAIN
PSYCO-PHYSICAL TREATMENTS-
ACCUPUNCTURE, MESSAGE,
RELAXATION, TENS
EXERCISE
ANTI-OESTROGEN DRUGS
LAPAROSCOPY/ OPEN SURGERY
LIMITATIONS OF DRUG
THERAPY
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
META-ANALYSIS MIN/MILD
ENDOMETRIOSIS
PREG n FOLLOW-
RATE UP
NO TREAT 44% 235 0.5-3

DRUG 41% 418 1- 5

THERAPY
SURGERY 65% 912 1-6

IVF 20 257