Endometriosiseshre2014

1. Endometriosis:
Diagnosis and
Management
ESHRE: 2014&
NICE: 2017 Guidelines
Prof. ABOUBAKR
ELNASHAR
Benha university, Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
I. DIAGNOSIS
II. TREATMENT OF PAIN ASSOCIATED
ENDOMETRIOSIS
III.TREATMENT OF INFERTILITY ASSOCIATED
ENDOMETRIOSIS
IV.OTHER
1. Menopause in women with endometriosis
2. Asymptomatic endometriosis
3. Prevention of endometriosis
4. Endometriosis & cancer
ABOUBAKR ELNASHAR

3. I. DIAGNOSIS
ABOUBAKR ELNASHAR

4. 1. Symptoms
Gynecologic:
1. Dysmenorrhoea
2. Non-cyclical pelvic pain
3. Deep dyspareunia,
4. Infertility
Non-gynecological cyclical
•Dyschezia
•Dysuria
•Haematuria
•Rectal bleeding
•Shoulder pain
(GPP)
ABOUBAKR ELNASHAR

5. Suspect endometriosis
(NICE, 2017)
 with 1 or more of the following symptoms or signs:
1. chronic pelvic pain
2. period-related pain (dysmenorrhoea) affecting daily
activities and quality of life
3. deep pain during or after sexual intercourse
4. period-related or cyclical gastrointestinal symptoms,
in particular, painful bowel movements
5. period-related or cyclical urinary symptoms, in
particular, blood in the urine or pain passing urine
6. infertility in association with 1 or more of the above.
ABOUBAKR ELNASHAR

6. 2. Examination
In all women suspected of endometriosis
Vaginal:
Rectal: adolescents and/or women without
previous sexual intercourse.
(GPP)
Deep endometriosis:
Painful induration and/or nodules of the rectovaginal
wall or
Visible vaginal nodules in the posterior vaginal fornix
(Bazot et al., 2009). (C)
ABOUBAKR ELNASHAR

7. Ovarian endometrioma
Adnexal masses
(Ripps and Martin, 1992; Koninckx et al., 1996; Eskenazi et al., 2001;
Condous et al., 2007; Bazot et al., 2009). {C}
Endometriosis
suspected even if the clinical examination is normal
(Chapron et al., 2002). {C}
ABOUBAKR ELNASHAR

8. 3. Investigations
1. Laparoscopy
with biopsy and histology:
gold standard for diagnosis
Negative diagnostic laparoscopy:
highly accurate for excluding endometriosis
Positive laparoscopy without taking biopsies
less informative
of limited value
(Wykes et al., 2004).
To obtain tissue for histology in women undergoing
surgery for
 endometrioma and/or
 deep infiltrating disease
{exclude rare instances of malignancy}
{GPP}
ABOUBAKR ELNASHAR

9. Histopathologic confirmation
necessary for the diagnosis of endometriosis
ectopic endometrial stroma and glands
(Berker, Seval, 2015)
ABOUBAKR ELNASHAR

10.  Diagnostic laparoscopy (NICE, 2017)
 Is considered in women with suspected
endometriosis, even if the ultrasound was normal.
 gynaecologist with training and skills in
laparoscopic surgery for endometriosis
 perform a systematic inspection of the pelvis.
ABOUBAKR ELNASHAR

11. 2. TVS:
To diagnose or to exclude
ovarian endometrioma
(Moore et al., 2002).{A}
 rectal endometriosis
(Hudelist et al., 2011).{A}
ABOUBAKR ELNASHAR

12. Diagnosis of endometrioma
•Ground glass echogenicity
•1-4 compartments
•No papillary structures
•Detectable blood flow
(Van Holsbeke et al., 2010).{GPP}
ABOUBAKR ELNASHAR

13. Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
ABOUBAKR ELNASHAR

14. Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts.ABOUBAKR ELNASHAR

15. 3D ultrasound
To diagnose rectovaginal endometriosis is not well
established
(Pascual et al., 2010).{D}
MRI
To diagnose peritoneal endometriosis is not well
established
(Stratton et al., 2003) {D}
 For women with suspected deep endometriosis
involving the bowel, bladder or ureter, consider a
 pelvic ultrasound or
 MRI before an operative laparoscopy.
(NICE, 2017)
ABOUBAKR ELNASHAR

16. MRI (NICE, 2017)
 Do not use pelvic MRI as the primary investigation
to diagnose endometriosis in women with
symptoms or signs suggestive of endometriosis.
 Consider pelvic MRI to assess the extent of deep
endometriosis involving the bowel, bladder or
ureter.
 Ensure that pelvic MRI scans are interpreted by a
healthcare professional with specialist expertise in
gynaecological imaging.
ABOUBAKR ELNASHAR

17. Biomarkers
Not recommended to diagnose endometriosis
in endometrial tissue, menstrual or uterine fluids
(May et al., 2011)
Immunological biomarkers
CA-125, in plasma, urine or serum
(Mol et al., 1998;May et al., 2010).{A}
ABOUBAKR ELNASHAR

18.  Serum CA125 (NICE, 2017)
 Do not use serum CA125 to diagnose
endometriosis.
 If a coincidentally reported serum CA125 level is
available, be aware that:
 a raised serum CA125 (that is, 35 IU/ml or
more) may be consistent with having
 endometriosis
 endometriosis may be present despite a
normal serum CA125 (less than 35 IU/ml).
ABOUBAKR ELNASHAR

19. Barium enema, TVS, TRS and MRI
To assess ureter, bladder and bowel involvement
if there is a suspicion (based on history or physical
examination) of deep endometriosis
for further management
{GPP}
ABOUBAKR ELNASHAR

20. Staging systems
(NICE, 2017)
 Offer endometriosis treatment according to the
 woman's symptoms,
 preferences and priorities, rather than the stage of
the endometriosis.
 When endometriosis is diagnosed, the gynaecologist
should document a detailed description of the
 appearance and
 site of endometriosis.
ABOUBAKR ELNASHAR

21. II. TREATMENT OF ENDOMETRIOSIS-
ASSOCIATED PAIN
ABOUBAKR ELNASHAR

22. Pathogenesis of endometriosis-associated pain
Central Sensitization
key factor in the in addition to the peripheral
nociceptive effect* of endometriotic lesions
(Hoffman, 2015).
amplifies pain signaling from the periphery
(Brawn et al , 2014).
It is associated with
Myofascial trigger points
(Stratton et al, 2015)
Psychological comorbidities
(Yosef et al, 2016).
*Pain that arises from damage to non-neural tissue.
due to the activation of nociceptors=
sensory receptor of the peripheral nervous system
ABOUBAKR ELNASHAR

23. ABOUBAKR ELNASHAR

24.  Central sensitisation
an important mechanism in endometriosis-
associated pain and CPP
Increased responsiveness of nociceptive neurons in
the CNS to their
normal or
sub-threshold afferent input:
 patient becomes more sensitive to peripheral
stimuli.
ABOUBAKR ELNASHAR

25.  Central sensitization:
may become independent of peripheral stimuli
{via neural mechanisms similar to those underlying
the generation of memory}:
generation of pain without a peripheral noxious
input.
This may be a reason
why pain can persist despite treatment of all
identified peripheral pathology
ABOUBAKR ELNASHAR

26.  EMPIRICAL TREATMENT OF PAIN
 counsel women with symptoms presumed to be
due to endometriosis thoroughly, and to empirically
treat them with
 Adequate analgesia
 COC or
 Progestagens.
ABOUBAKR ELNASHAR

27.  Clinicians are recommended to prescribe hormonal
treatment
 hormonal contraceptives (Level B)
 progestagens (Level A)
 anti-progestagens (Level A) or
 GnRH agonists (Level A)] as one of the options, as
it reduces endometriosis-associated pain
(Vercellini et al.,1993; Brown et al., 2010, 2012).
ABOUBAKR ELNASHAR

28.  Clinicians take into consideration when choosing
hormonal treatment for endometriosis-associated
pain.
 Patient preferences
 Side effects
 Efficacy,
 Costs and
 Availability (GPP)
ABOUBAKR ELNASHAR

29.  Hormonal contraceptives.
 COC:
{reduces endometriosis-associated dyspareunia,
dysmenorrhoea and non-menstrual pain}
(Vercellini et al., 1993).B
 continuous use in women suffering from
endometriosis-associated dysmenorrhoea
 ±consider
 vaginal contraceptive ring or
 transdermal (oestrogen/progestin) patch
(Vercellini et al., 2010).C
ABOUBAKR ELNASHAR

30. ABOUBAKR ELNASHAR

31.  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
(Brown et al., 2012).A
ABOUBAKR ELNASHAR

32. Dose:
Continuously:
Progestagens given in the luteal phase are not
effective
DoseNamePreparation
30mg/dProveraMPA
150mg/1- 3 mo, IM.Depo proveraDMPA
10-20 mg/d.Primoult norNoreethisterone acetate
20 mg/dDuphastonDydrogestrone
2mg/dVisanneDienogest
ABOUBAKR ELNASHAR

33.  Take in consideration
 side-effect especially irreversible side effects
e.g. thrombosis and androgenic side effects. GPP
 Consider prescribing
 LNG-IUS as one of the options to reduce
endometriosis-associated pain
(Petta et al., 2005; Gomes et al., 2007;Ferreira et al., 2010).
ABOUBAKR ELNASHAR

34. GnRH agonists
 Nafarelin, leuprolide, buserelin, goserelin or
triptorelin, as one of the options for reducing
endometriosis-associated pain
 Evidence is limited regarding dosage or duration
(Brown et al., 2010).A
 Careful consideration in young women and
adolescents, since these women may not have
reached maximum bone density. GPP
ABOUBAKR ELNASHAR

35.  Hormonal add-back therapy to coincide with the start
of GnRHagonist therapy
{prevent bone loss and hypoestrogenic symptoms
during treatment}.
 This is not known to reduce the effect of treatment on
pain relief
(Makarainen et al., 1996; Bergqvist et al., 1997; Taskin et al., 1997;
Moghissi et al., 1998). A
ABOUBAKR ELNASHAR

36. PricecompanyDoseRouteNamePreparation
861/28
30
Abbvie2.8 mg
0.1 mgIM, SCLucrin
Leuprorelin
500Astrazenica3.6 mgSCZoladexGoserelin
605
53
FerringCR: 3.75mg
0.1mg
IM, SCDecapeptylTriptolerin
46Ibsa0.1mgIM, SCTriptofem
Sanofi0.5 mgNasal, SCsuperfactBuserelin
Pfaizer0.2 mg bidnasalSynarelNafarelin
ABOUBAKR ELNASHAR
Types of agonist

37. •Estrogen-progestagen combination
•Tibilone (livial): 2.5 mg/d.
Bisphosphonates: Etidronate.
ABOUBAKR ELNASHAR

38.  Aromatase inhibitors.
 In women with pain from
 Rectovaginal endometriosis
 Refractory to other medical or surgical treatment
 in combination with
 COC,
 progestagens or
 GnRH analogues, as they reduce endometriosis-
associated pain
(Nawathe et al., 2008; Ferrero et al., 2011).B
ABOUBAKR ELNASHAR

39. Anastrazole (Arimidex): 1mg/d
Letrozole (Femara): 2.5 mg/d
Both are approved in USA for tt of breast cancer.
ABOUBAKR ELNASHAR

40. Analgesics
 NSAIDs or
 other analgesics to reduce endometriosis-associated pain.
 Useful in women trying to conceive
 ibuprofen (Sapofen)
naproxen (Naprosyn).
Mefenamic acid (Ponstan)
 Start 2 d before menstruation, Similar efficacy
 Gastric irritation.
ABOUBAKR ELNASHAR

41.  Cyclooxygenase-2 (COX-2).
 Celebrex
 Vioxx
 Not more effective (than naproxen or ibuprofen)
 lower risk of gastric ulceration
 high cost
(Mahutte & Arici, 2003)
ABOUBAKR ELNASHAR

42.  Analgesics (NICE, 2017)
 discuss the benefits and risks of analgesics, taking
into account
 any comorbidities and
 woman's preferences.
 Consider a short trial (for example, 3 months) of
 paracetamol or a
 non-steroidal anti-inflammatory drug (NSAID)
alone or in combination for first-line management
of endometriosis-related pain.
ABOUBAKR ELNASHAR

43.  If a trial of paracetamol or an NSAID (alone or in
combination) does not provide adequate pain relief:
 consider other forms of pain management and
 referral for further assessment.
ABOUBAKR ELNASHAR

44.  Neuromodulators and neuropathic pain treatments
 Offer a choice of amitriptyline, duloxetine,
gabapentin (Lyrica, Gapten)) or pregabalin as
initial treatment for neuropathic pain
 Treatments to reduce central sensitization are
 required in some patients
 Tricyclics and antiepileptics
 Multidisciplinary approach
 Physiotherapy
 Psychological therapy
(Peters et al, 1992)
ABOUBAKR ELNASHAR

45.  SURGERY
 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’
(Jacobson et al.,2009)A
ABOUBAKR ELNASHAR

46.  Consider both ablation and excision of peritoneal
endometriosis to reduce endometriosis-associated
pain
(Wright et al.,2005; Healey et al., 2010).C
 Ovarian endometrioma:
 cystectomy instead of drainage and coagulation,
{cystectomy reduces endometriosis-associated
pain}
(Hart et al., 2008). A
 cystectomy rather than CO2 laser vaporization
{lower recurrence rate}
(Carmona et al., 2011). B
ABOUBAKR ELNASHAR

47.  Deep endometriosis
 Consider surgical removal
{reduces endometriosis-associated pain and
improves quality of life}
(DeCicco et al., 2011; Meuleman et al., 2011a, b).B
 Refer women with suspected or diagnosed deep
endometriosis to a centre of expertise that offers
all available treatments in a multidisciplinary
context. GPP
 As an adjunct to surgery for deep endometriosis
involving the bowel, bladder or ureter, consider 3
months of gonadotrophin-releasing hormone
agonists before surgery.
ABOUBAKR ELNASHAR

48.  HYSTERECTOMY.
 with removal of the ovaries and all visible
endometriosis lesions in
 women who have completed their family and
 failed to respond to more conservative treatments.
 Women should be informed that
 hysterectomy will not necessarily cure the
symptoms or the disease.
GPP
ABOUBAKR ELNASHAR

49.  laparoscopic uterosacral nerve ablation (LUNA)
 Not perform
 as an additional procedure to conservative surgery
to reduce endometriosis-associated pain
(Proctor et al., 2005).A
 Presacral neurectomy (PSN)
 effective as an additional procedure to
conservative surgery to reduce endometriosis-
associated midline pain
 requires a high degree of skill
 potentially hazardous procedure
(Proctor et al., 2005).A
ABOUBAKR ELNASHAR

50.  Hysterectomy in combination with surgical
management (NICE, 2017)
 If hysterectomy is indicated
 woman has adenomyosis or
 heavy menstrual bleeding that has not responded
to other treatments:
 excise all visible endometriotic lesions at the
time of the hysterectomy.
 Perform hysterectomy (with or without oophorectomy)
laparoscopically when combined with surgical
treatment of endometriosis, unless there are
contraindications.
ABOUBAKR ELNASHAR

51.  For women thinking about having a hysterectomy,
discuss:
 what a hysterectomy involves and when it may be needed
 the possible benefits and risks of hysterectomy
 the possible benefits and risks of having oophorectomy at
the same time
 how a hysterectomy (with or without oophorectomy) could
affect endometriosis symptoms
 that hysterectomy should be combined with excision of all
visible endometriotic lesions
 endometriosis recurrence and the possible need for further
surgery
 the possible benefits and risks of hormone replacement
therapy after hysterectomy with oophorectomy
ABOUBAKR ELNASHAR

52.  Prevention of adhesion during laparoscopy
 oxidized regenerated cellulose
 Beneficial
(Ahmad et al., 2008). B
 Icodextrin
 no benefit
(Brown et al., 2007; Trew et al., 2011). B
 other anti-adhesion agents
 polytetrafluoroethylene surgical membrane
 hyaluronic acid products:
 effective for adhesion prevention in the context
of pelvic surgery, although not specifically in
women with endometriosis.
GPP
ABOUBAKR ELNASHAR

53.  Preoperative hormonal therapies effective for
treatment of pain?
 No
(Furness et al., 2004).A
 Clearly distinguish
 adjunctive short-term (≤6 months) hormonal
treatment after surgery from
 long-term (≥6 months) hormonal treatment; the
latter is aimed at secondary prevention. GPP
 not prescribe adjunctive hormonal treatment in
women with endometriosis for endometriosis-
associated pain after surgery, as it does not
improve the outcome of surgery for pain
(Furness et al., 2004).A
ABOUBAKR ELNASHAR

54.  Secondary prevention of disease and painful
symptoms in women treated for endometriosis
 defined as
 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.
 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
 side effects.
 For many interventions that might be considered here, there are limited data.
GPP
ABOUBAKR ELNASHAR

55.  In women operated on for an endometrioma (≥3 cm):
 ovarian cystectomy, instead of drainage and
electrocoagulation, for the secondary prevention of
endometriosis-associated dysmenorrhoea,
dyspareunia and non-menstrual pelvic pain
(Hart et al., 2008).A
 After cystectomy for ovarian endometrioma in
women not immediately seeking conception:
 COC for the secondary prevention of
endometrioma
(Vercellini et al., 2010).A
ABOUBAKR ELNASHAR

56.  In women operated on for endometriosis:
 post-operative use of a LNG-IUS or a
 combined hormonal contraceptive
 for at least 18–24 months
 as one of the options for the secondary prevention of endometriosis-associated
dysmenorrhoea, but not for non-menstrual pelvic pain or dyspareunia
(Abou-Setta et al., 2006; Seracchioli et al., 2009). A
ABOUBAKR ELNASHAR

57.  Extragenital endometriosis
 can affect different tissues and body parts outside the genital tract.
 Pain is the most common presenting symptom,
although a wide range of symptoms can manifest.
 The evidence of the results of the different options to treat extragenital
endometriosis is limited and mainly published in case reports resulting in Level
D recommendations.
 Consider surgical removal of symptomatic
extragenital endometriosis, when possible, to
relieve symptoms
(Liang et al., 1996; Marinis et al., 2006; Nisolle et al., 2007; Nissotakis et al.,
2010; Nezhat et al., 2011; Song et al., 2011). D
 When surgical treatment is difficult or impossible:
 medical treatment of extragenital endometriosis
to relieve symptoms
(Bergqvist, 1992; Joseph and Sahn, 1996; Jubanyik and Comite, 1997).
D
ABOUBAKR ELNASHAR

58.  OTHER PAIN MANAGEMENT STRATEGIES
 does not recommend the use of
 nutritional supplements
 complementary or alternative medicine
{potential benefits and/or harms are unclear}.
 some women who seek complementary and
alternative medicine may feel benefit from this.
GPP
ABOUBAKR ELNASHAR

59. III. TREATMENT OF
ENDOMETRIOSIS ASSOCIATED
INFERTILITY
ABOUBAKR ELNASHAR

60. Mechanism of infertility
(Prentice, 2001)
I- Advanced disease:
Mechanical interference with
Ovulation
Ovum pick up
Tubo-ovarian adhesion
Distorted tubal anatomy.
ABOUBAKR ELNASHAR

61. II- Minimal & mild disease:
1. Coital problems: dysparunia.
2. Altered peritoneal environment:
increase
volume of peritoneal fluid
activated macrophages:
phagocytosis of sperms
decreased sperm motility
embyotoxicty
3. Altered foliccular maturation:
lutenized unruptured follicle
anovulation
luteolysis caused by prostaglandin F2
No evidence that they are more common in E.
ABOUBAKR ELNASHAR

62. 1. Hormonal therapies
No need
For suppression of ovarian function to improve
fertility
(Hughes et al., 2007).{A}
hormonal contraceptives,
Progestagens
GnRH analogues or
Danazol
to improve fertility in minimal to mild endometriosis is not effective and
should not be offered for this indication alone.
The published evidence does not comment on more severe disease
(Hughes et al., 2007).
ABOUBAKR ELNASHAR

63. 2. Nutritional supplements, complementary
and alternative treatments
No evidence for a beneficial effect
(GPP)
ABOUBAKR ELNASHAR

64. 2. Surgery
Stage I/II:
•Operative laparoscopy:
excision or
ablation of the endometriosis lesions
adhesiolysis
rather than
•Diagnostic laparoscopy only, to increase PR
(Nowroozi et al., 1987; Jacobson et al., 2010).{A}
ABOUBAKR ELNASHAR

65. CO2 laser vaporization of endometriosis, instead of
monopolar electrocoagulation
{higher cumulative spontaneous PR }
(Chang et al., 1997).{C}
 Offer excision or ablation of endometriosis plus
adhesiolysis for endometriosis not involving the
bowel, bladder or ureter, because this improves the
chance of spontaneous pregnancy.
ABOUBAKR ELNASHAR

66. Endometrioma
Excision of the capsule
instead of drainage and electrocoagulation of the
endometrioma wall
{increase spontaneous PR}
(Hart et al., 2008).{A}
ORT
If compromised: surgery is not recommended
Counseling:
Risks of reduced ovarian function after surgery
ABOUBAKR ELNASHAR

67. Stage III/IV
Operative laparoscopy, instead of expectant
management:
increase spontaneous PR
(Nezhat et al., 1989; Vercellini et al.,2006). {B}
Spontaneous PR of
(Olive et al., 1985; Nezhat et al., 1989; Vercellini et al., 2006).
After expectant
management
After operative
laparoscopy
Stage
33%52-68%III
0%57-69%IV
ABOUBAKR ELNASHAR

68. Hormonal treatment
Before surgery to improve spontaneous PR:
No
{evidence is lacking}
(GPP)
For pain
Yes
(GPP)
After surgery to improve spontaneous PR
No
(Furness et al., 2004).{A}
ABOUBAKR ELNASHAR

69. 3. IUI WITH COS
instead of expectant management
In Stage I/II
{increases LBR}
(Tummon et al., 1997).{C}
within 6 months after surgical TT:
{PR are similar to those achieved in unexplained
infertility }
(Werbrouck et al., 2006). {C}
ABOUBAKR ELNASHAR

70. 4. IVF
Indications
1. Age ≥38 y
2. Infertility is long lasting.
3. Diminished ovarian reserve
4. Tubal function is compromised
5. Male factor infertility
6. Bilateral endometriomas
7. Other treatments have failed.
8. Prior surgical treatment
In patients who failed to conceive spontaneously
after surgery: ART is more effective than repeat
surgery.
{GPP; Polat et al, 2015)
After surgery
{cumulative endometriosis recurrence rates are not increased after COS for IVF/ICSI}
(D’Hooghe et al., 2006; Benaglia et al., 2010;Coccia et al., 2010; Benaglia et al., 2011). {C}
ABOUBAKR ELNASHAR

71. Nonovarian disease:
Surgical resection
has not been consistently shown to improve
outcomes with the possible exception of resection of
deeply invasive disease, although the data is limited.
(Surrey, 2015)
ABOUBAKR ELNASHAR

72. Indications for Resection of a Suspected
Endometrioma prior to IVF
(Surrey et al, 2015)
1. Rapid growth
2. Suspicious features noted on ultrasound
3. Painful symptoms that can be attributed to the
mass
4. Potential for rupture in pregnancy
5. Inability to access follicles in normal ovarian
tissue.
ABOUBAKR ELNASHAR

73. Deep endometriosis
The effectiveness of surgical excision is
not well established with regard to reproductive
outcome
(Bianchi et al.,2009; Papaleo et al., 2011).{C}
ABOUBAKR ELNASHAR

74. GnRHa for a period of 3–6 months prior to treatment
with ART: improve PR
(Sallam et al., 2006). {B}
ORT: compromised
Long agonist protocol
A benefit (which did not reach clinical significance)
only when fresh and cryopreserved embryo transfers were combined.
(Houwen et al, 2014)
Significant benefit was noted only among patients stages III and IV
(Rickes et al, 2002)
ABOUBAKR ELNASHAR

75. At Oocyte retriveal
Antibiotic prophylaxis
(Benaglia et al., 2008).{D}
ABOUBAKR ELNASHAR

76. ABOUBAKR ELNASHAR

77. IV. OTHER ISSUES
ABOUBAKR ELNASHAR

78. 1. MENOPAUSE IN WOMEN WITH ENDOMETRIOSIS
 In women with surgically induced menopause
because of endometriosis:
 oestrogen/progestagen therapy or tibolone can be
effective for the treatment of menopausal
symptoms
(Al Kadri et al., 2009). B
 continue to treat at least up to the age of natural
menopause.
ABOUBAKR ELNASHAR

79.  Post-menopausal women after hysterectomy and with
a history of endometriosis:
 avoid unopposed oestrogen treatment.
 However, the theoretical benefit of avoiding disease
reactivation and malignant transformation of residual disease
should be balanced against the increased systemic risks
associated with combined oestrogen/progestagen or tibolone.
GPP
ABOUBAKR ELNASHAR

80. 2. ASYMPTOMATIC ENDOMETRIOSIS
 should not routinely perform surgical excision and
ablation for an incidental finding of asymptomatic
endometriosis at the time of surgery, since the natural
course of the disease is not clear.
GPP
 fully inform and counsel women about any incidental
finding of endometriosis
ABOUBAKR ELNASHAR

81. 3. PRIMARY PREVENTION OF ENDOMETRIOSIS
 The usefulness of oral contraceptives for the primary
prevention of endometriosis is uncertain
 (Vercellini et al., 2011). C
 The usefulness of physical exercise for the primary
prevention of endometriosis is uncertain
(Vitonis et al., 2010). C
ABOUBAKR ELNASHAR

82. 4. ENDOMETRIOSIS AND CANCER
 no evidence that endometriosis causes cancer
 no increase in overall incidence of cancer in women
with endometriosis
 some cancers
 ovarian cancer and
 non-Hodgkin’s lymphoma are slightly more
common in women with endometriosis.
 explain the incidence of some cancers in women with endometriosis in absolute numbers.
 no change in management of endometriosis in
relation to malignancies, since there are no clinical
data on how to lower the slightly increased risk of
ovarian cancer or non-Hodgkin’s lymphoma in women
with endometriosis.
 GPP
ABOUBAKR ELNASHAR

83. You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura
ABOUBAKR ELNASHAR