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Endometriosis An Enigmatic Disease, DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyoti Bhaskar

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ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE
Endometriosis: The Pain That Keeps on Giving
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”


Published in: Health & Medicine

Endometriosis An Enigmatic Disease, DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyoti Bhaskar

  1. 1. Endometriosis An Enigmatic Disease DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyoti Bhaskar …Caring hearts, healing hands
  2. 2. ENDOMETRIOSIS STILLAN ENIGMATIC DISEASE …Caring hearts, healing hands EndometriosisThe Pain That Keeps on Giving
  3. 3. “Endometriosis remains a riddle wrapped in a mystery inside an enigma” …Caring hearts, healing hands
  4. 4. •Diagnostic Dilemma •Debilitating Disease •Progressive Disease •Disease with “No Cure” •H/O Multiple Operations • A Gynaecologist’s dilemma
  5. 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. 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
  7. 7. March is Endometriosis Awareness Month
  8. 8. ” Definition “Presence of endometrial tissue outside the lining of the uterine cavity or “Proliferation of endometrium in any site other than the uterine mucosa’’
  9. 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. 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--- ?
  11. 11. PREVALENCE •10% Prevalence is higher in women with • Dysmenorrhea : upto 60% • Dyspareunia : upto 44% • Pelvic Pain : upto 80%
  12. 12. AGE AT DIAGNOSIS
  13. 13. 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
  14. 14. 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 ?
  15. 15. Pathogenesis I- Endometrial implantation: Retrograde. II Vascular & lymphatic. Mechanical. III- In situ development: Coelomic metaplasia. Induction. IV- Immunological. V- Composite.
  16. 16. Endometriosis is said to be Estrogen dependent . It is one of the major causative factors in the development of endometriosis. Pathogenesis ??
  17. 17. Excess Estrogen stimulates Inflammation Invasion Angiogenesis Cell Proliferation Adhesions Pain
  18. 18. 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.
  19. 19. 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%.
  20. 20. 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.
  21. 21. REVISED AFS (1985) • Stage I (minimal) 1 – 5. • Stage II (mild) 6 – 15. • Stage III (moderate) 16 – 40. • Stage IV (severe) > 40.
  22. 22. Symptoms Infertility 40 % Dysmenorrhoea 60 % Chronic Pelvic Pain 80% Pain Premenstrual Intramenstrual Postmenstrual 100% Dyspareunia 45 % Absolutely asymtomatic….to most miserable
  23. 23. IN WOMEN OF REPRODUCTIVE AGE WITH NON-GYNAECOLOGICAL CYCLICAL SYMPTOMS • Dyschezia • Dysuria • Haematuria • Rectal bleeding • Shoulder pain.
  24. 24. 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
  25. 25. • It should include both- • Per Abdomen • Per Speculum • Per Vaginum • Highest predictive value • -- Menstruation In all women suspected of endometriosis
  26. 26. 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
  27. 27. 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
  28. 28. Consider Ovarian Endometriosis Adnexal Masses detected during clinical examination
  29. 29. Be Obsessed with Endometriosis • In women suspected of the disease even if the clinical examination is NORMAL
  30. 30. Transvaginal Ultrasound First-line investigational tool • Findings: Cysts / nodules 1.Anechoic to echogenic cysts 2.Masses containing multiple septations & solid tissue (Morane &Older, 1996) 3.Cysts with low-level echoes: The commonest finding (95%)
  31. 31. Ovarian Endometrioma Perform TVS Classical Endometrioma
  32. 32. Magnetic Resonance Imaging ???? • Clinicians should be aware that the usefulness of magnetic resonance imaging (MRI) to diagnose Peritoneal Endometriosis is not well established
  33. 33. 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
  34. 34. Treatment : Consideration • Age. • Symptoms. • Stage. • Infertility.
  35. 35. 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
  36. 36. 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
  37. 37. ESHRE guidelines 2014 Best so far For Treatment Will answer all your queries
  38. 38. 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
  39. 39. 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.
  40. 40. •Diagnostic Dilemma •Debilitating Disease •Progressive Disease •Disease with “No Cure” •H/O Multiple Operations TAKE HOME MESSAGE
  41. 41. • 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
  42. 42. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 Helpline 9650588339, 011-22414049, 011-22058865 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com &

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