Best Clinical Practice Guidelines Ever Produced on Management of Endometriosis


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Best Clinical Practice Guidelines Ever Produced on Management of Endometriosis

  1. 1. Management of Endometriosis ESHRE GUIDELINES 2013 Best Clinical Practice Guidelines Ever Produced on Dr. Jyoti Bhaskar Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Namitha kapoor
  2. 2. Which symptoms areWhich symptoms are associated with or predictive ofassociated with or predictive of the diagnosis ofthe diagnosis of endometriosis?endometriosis? ? BIGQUESTION1
  3. 3. Delay to Diagnosis 8 to 10 years 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--- ?
  4. 4. In the presence of gynaecological symptoms such as: • dysmenorrhoea – 40% • non-cyclical pelvic pain– upto 80% • deep dyspareunia – 44% • infertility -- 40% • fatigue in the presence of any of the above. Clinicians should consider the diagnosis of Endometriosis:
  5. 5. In women of reproductive age with non-gynaecological cyclical symptoms: • dyschezia • dysuria • haematuria • rectal bleeding • shoulder pain.
  6. 6. What findings during clinical examination are predictive for the Presence and localization of pelvic endometriosis? BIGQUESTION2 ?
  7. 7. Clinicians should perform Clinical Examination in all women suspected of endometriosis • It should include both- • Per Abdomen • Per Speculum • Per Vaginum • Highest predictive value • -- Menstruation
  8. 8. 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
  9. 9. 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
  10. 10. Consider Ovarian Endometriosis Adnexal Masses detected during clinical examination
  11. 11. Be Obsessed with Endometriosis • In women suspected of the disease even if the clinical examination is NORMAL
  12. 12. Can the diagnosis ofCan the diagnosis of endometriosis be made byendometriosis be made by application of specificapplication of specific medical technologies?medical technologies? ? BIGQUESTIONNO.3BIGQUESTIONNO.3
  13. 13. The Diagnosis of Endometriosis Based on the • History • Symptoms and signs, • Corroborated by physical examination & imaging techniques • And finally proven by histological examination of specimens collected during laparoscopy
  14. 14. Laproscopy & Histology – Gold Standard • Perform a laparoscopy to diagnose endometriosis • Confirm a positive laparoscopy by histology, since positive histology confirms the diagnosis of endometriosis even though negative histology does not exclude it. • Clinicians should obtain tissue for histology to exclude rare instances of malignancy.
  15. 15. Ovarian Endometrioma Perform TVS diagnose or to exclude an ovarian Endometrioma
  16. 16. Ultrasound features • Ultrasound characteristics in premenopausal women 1. Ground Glass echogenicity 2. one to four compartments 3. no papillary structures with detectable blood flow
  17. 17. Ultrasound for Rectal Endometriosis • TVS is highly operator dependent, and experience is often lacking • TVS is not recommended for diagnosis of rectal endometriosis • 3D ultrasound to diagnose rectovaginal endometriosis is not well established
  18. 18. • Clinicians should assess ureter, bladder and bowel involvement by additional imaging if there is a suspicion based on history or physical examination of deep endometriosis. • Barium enema, Transvaginal sonography (TVS), Transrectal sonography and MRI DEEP ENDOMETRIOSIS
  19. 19. Magnetic Resonance Imaging ???? • Clinicians should be aware that the usefulness of magnetic resonance imaging (MRI) to diagnose Peritoneal Endometriosis is not well established
  20. 20. 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
  21. 21. Treatment of Endometriosis-associated Pain
  22. 22. Empirical treatment of pain ?Empirical treatment of pain ? ? BIGQUESTIONNO.4BIGQUESTIONNO.4
  23. 23. Clinicians should • Counsel women with symptoms presumed to be due to endometriosis thoroughly • Empirically treat them with 1. adequate analgesia, 2. combined hormonal contraceptives or progestagens.
  24. 24. Are hormonal therapiesAre hormonal therapies effective for painful symptomseffective for painful symptoms associatedassociated with endometriosis?with endometriosis? ? BIGQUESTIONNO.5BIGQUESTIONNO.5
  25. 25. Clinicians are recommended • Prescribe hormonal treatment as one of the options 1. Hormonal contraceptives 2. Progestagens 3. Anti-progestagens 4. GnRH agonists • To take patient preferences, side effects, efficacy, costs and availability into consideration when choosing hormonal treatment
  26. 26. Progestagens and anti-progestagens. PROGESTAGENS [medroxyprogesterone acetate (oral or depot), dienogest, cyproterone acetate, norethisterone acetate or danazol] or ANTI-PROGESTAGENS (gestrinone) as one of the options, to reduce endometriosis-associated pain • To take the different side-effect profiles of progestagens and anti-progestagens into account
  27. 27. LNG-IUS • To consider levonorgestrel-releasing intrauterine system (LNG-IUS) as one of the options to reduce endometriosis-associated pain
  28. 28. GnRH Agonist • Use GnRH agonists (nafarelin,leuprolide, buserelin, goserelin or triptorelin), although evidence is limited regarding dosage or duration of treatment • Prescribe hormonal add-back therapy to coincide with the START of GnRH agonist therapy • To give careful consideration in young women and adolescents
  29. 29. Aromatase inhibitors • In women with pain from rectovaginal endometriosis, refractory to other medical or surgical treatment, Consider prescribing aromatase inhibitors in combination with oral contraceptive pills, progestagens or GnRH analogues
  30. 30. Are analgesics effective forAre analgesics effective for symptomatic relief of painsymptomatic relief of pain associated withassociated with endometriosis?endometriosis? BIGQUESTIONNO.6BIGQUESTIONNO.6
  31. 31. The GDG recommends that clinicians should consider NSAIDs or other analgesics to reduce endometriosis-associated pain. NSAIDS
  32. 32. Is surgery effective for painfulIs surgery effective for painful symptoms associated withsymptoms associated with endometriosis?endometriosis? ? BIGQUESTIONNO.7BIGQUESTIONNO.7
  33. 33. Laparotomy and laparoscopy are equally effective Laparoscopic surgery is usually associated • with less pain, • shorter hospital stay • quicker recovery • better cosmetic outcome, Laparoscopy is usually preferred
  34. 34. • When endometriosis is identified at LAPAROSCOPY, clinicians are recommended to surgically treat endometriosis, as this is effective for reducing endometriosis- associated pain, i.e. ‘SEE AND TREAT’
  35. 35. • Clinicians may consider both ablation and excision of peritoneal endometriosis • Excision of lesions could be preferential PERITONEAL ENDOMETRIOSIS
  36. 36. Ovarian Endometrioma CYSTECTOMY • PERFORM CYSTECTOMY instead of drainage and coagulation, as cystectomy reduces endometriosis-associated pain • CYSTECTOMY NOT CO2 laser vaporization because of a lower recurrence rate of the endometrioma
  37. 37. Deep Endometriosis • Clinicians can consider performing Surgical removal of deep endometriosis, as it reduces endometriosis-associated pain and improves quality of life
  38. 38. Hysterectomy • Hysterectomy with removal of the ovaries and all visible endometriosis lesions 1. in women who have completed their family 2. failed to respond to more conservative treatments. . Women should be informed that hysterectomy WILL NOT necessarily cure the symptoms or the disease.
  39. 39. Surgical interruption of pelvic nerve pathways. • Clinicians should not perform laparoscopic uterosacral nerve ablation (LUNA) • Clinicians should be aware that presacral neurectomy (PSN) is effective to reduce endometriosis-associated midline pain, but it requires a high degree of skill and is a potentially hazardous procedure
  40. 40. Are preoperative hormonal therapies effective for treatment of pain? • Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of surgery for pain in women with endometriosis
  41. 41. Are short-term post-operativeAre short-term post-operative hormonal therapies effective forhormonal therapies effective for treatmenttreatment of pain?of pain? ? BIGQUESTIONNO.8BIGQUESTIONNO.8
  43. 43. Is there a role for secondaryIs there a role for secondary prevention of disease and painfulprevention of disease and painful symptoms in women treated forsymptoms in women treated for endometriosis?endometriosis? ? BIGQUESTIONNO.9BIGQUESTIONNO.9
  44. 44. Secondary Prevention • Interventions to prevent the recurrence of pain symptoms or the recurrence of disease in the long- term, defined as more than 6 months after surgery. • The GDG states that there is a role for prevention of recurrence of disease and painful symptoms in women surgically treated for endometriosis. • The choice of intervention depends on patient preferences, costs, availability and side effects.
  45. 45. • In women operated on for an endometrioma (≥3 cm), Ovarian Cystectomy, instead of drainage and electrocoagulation • After cystectomy in women not immediately seeking conception, prescribe combined hormonal contraceptives Secondary Prevention of Ovarian Endometrioma
  46. 46. • Post-operative use of a LNG-IUS or a combined hormonal contraceptive for at least 18–24 months, SECONDARY PREVENTION OF ENDOMETRIOSIS Endometriosis-associated dysmenorrhoea, not for non-menstrual pelvic pain or Dyspareunia
  47. 47. Extragenital EndometriosisExtragenital EndometriosisBIGQUESTIONNO.10BIGQUESTIONNO.10
  48. 48. • Surgical removal of symptomatic extragenital endometriosis, when possible, to relieve symptoms • When surgical treatment is difficult or impossible, Medical treatment of extragenital endometriosis to relieve symptoms EXTRAGENITAL ENDOMETRIOSIS
  49. 49. CASE STUDY Our Experience at Lifecare • CASE 1 • A 19 old girl with pain abdomen. • P/A – a mass upto 16 weeks. • USG – Bilateral Ovarian endometrioma
  50. 50. • Patient and parents counselled 1. Modality of treatment – NEEDS SURGERY 2. Loss of Ovarian tissue 3. Recurrence ( 20% in 2 years, 50% in 5 years) • Underwent laproscopy bilateral cystectomy. • Put on combined continuous oral contraceptives. • Two year follow up – no recurrence.
  51. 51. Case 2 • 26 year old , P2 , does not want a child • Dysmenorrhea and dyspareunia. • P/V – fixed retroverted uterus, tender • TVS – adherent ovaries , restricted mobility adenomyosis
  52. 52. • Treatment Offered: Laparoscopy with ablation of deposits and adhesiolysis • Mirena inserted at same sitting • Patient is asymptomatic at 1 year follow up.
  53. 53. TAKE HOME MESSAGE • High Suspicion of Endometriosis • Emperical Medical Treatment can be started without confirmation by Laproscopy • Laproscopy with histology is the gold standard. • Always SEE and TREAT on Laproscopy • Use modalities for Secondary Prevention after surgery
  54. 54. Thank You !!!
  55. 55. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : E-MAIL ID &