This document discusses the case of a 38-year-old woman with a long history of progressive endometriosis and the various treatments she underwent. She experienced persistent severe pain despite multiple surgeries and medical treatments. Her condition eventually required extensive surgery involving her colon, which resulted in her death due to complications. The document also provides information on the types and locations of endometriosis lesions and the challenges in diagnosing and managing this condition.

1. Endometriosis
:
Pain
Management
Dr.
Kawita
Bapat
DR.
KAWITA
BAPAT

2. Unlucky
PaBent
Unlucky
Gynecologist
“Born
with
pain,
died
with
pain
science
fails.”
“Endometriosis
and
women’s
health
tragedy
to
the
women
challenge
to
the
Gynaecologist.”
DR.
KAWITA
BAPAT

3. • 38
Years
• Progressive
Dysmenorrhea
• Since
Menarche
• Laparotomy
Done
At
The
Age
Of
16
Yrs.
• Bilateral
Cyst
Of
Ovary.
• Relieved
For
6
Months
• Taking
Analgesics
Off
And
On.
• Married
At
Age
20
Yrs.
• InvesBgated
For
InferBlity.
• DiagnosBc
Laparoscopy
Done
Twice
• PersisBng
Pain.
DR.
KAWITA
BAPAT

4. Ureteric
StenBng
For
3
SiXngs
PersisBng
Pain
And
InferBlity
IUI
6
SiXngs
IVF
3
SiXngs
• Progesterone
• Danazol
• GNRH
Analogue
• Depoprovera
For
Year
DR.
KAWITA
BAPAT

5. • PersisBng
severe
pain
• Adenomatous
uterus
and
chocolate
cyst
• Planned
for
laparoscopic
hysterectomy
with
bilateral
salpingo
oophorectomy
at
36
yrs.
• Frozen
pelvis
• Conversion
to
laparotomy
• Relieved
symptoms
for
6
months
only
DR.
KAWITA
BAPAT

6. • A^er
6
Months.
• EndometrioBc
Nodule
In
Vault
And
Post
Fornix
With
CysBc
Lumping.
• Sonography
Reveals
Residual
Endometriosis
Cyst
With
Evidence
Of
Vault
Endometriosis
• Not
Relieved
With
Medical
Management.
DR.
KAWITA
BAPAT

7. “Pathy
To
Pathy,
• Baba
To
Mama.”
• Tiruparhi
To
Pashupathi
• A`empted
Suicide
Twice.
• Decided
Surgery
With
Colorectal
Surgery.
• Excision
Of
Cyst
• Rectosignoisd
Lesions.
• UreBc
DissecBon
With
StenBng
• Colostomy.
DR.
KAWITA
BAPAT

8. • Closure
of
Colostomy
done
a^er
3
months
• Died
on
4th
P.O.
day
due
to
blood
transfusion
reacBon
DR.
KAWITA
BAPAT

9. Leaving
endometriosis
“Living
with
endometriosis
this
is
my
idea”
• Academic
obesity
• EssenBal-­‐Now
a
days
DR.
KAWITA
BAPAT

10. Endometriosis
• Invasive
And
Noninvasive
Diagnosis
Of
Endometriosis,
In
The
Context
Of
Pain
Symptoms
Or
InferBlity.
• The
DiagnosBc
Value
Of
Laparoscopy,
Imaging,
Serum
Markers,
Or
Endometrial
Biopsy
Depends
On
Clinical
Context
And
Treatment
Goals.
DR.
KAWITA
BAPAT

11. Endometriosis
• The
correlaBon
between
lesions
and
pain
symptoms
or
inferBlity
in
endometriosis
is
poorly
understood.
• There
is
a
wide
spectrum
of
symptom
severity,
and
the
stage
of
endometriosis
on
laparoscopy
correlates
poorly
with
the
extent
and
severity
of
pain.
• Some
paBents
with
minimal
disease
have
debilitaBng
pain,
while
other
women
with
severe
stage
III–IV
disease
are
asymptomaBc.
DR.
KAWITA
BAPAT

12. Types
and
locaBons
of
endometrioBc
lesions
• Deep
infiltraBng
endometriosis
(DIE)
• A
nodular
blend
of
fibromuscular
Bssue
• and
adenomyosis.
• These
lesions
are
• primarily
found
in
the
uterosacral
ligaments
or
cul
de
sac,
but
may
also
involve
the
rectovaginal
septum.
• DIE
may
present
with
• deep
dyspareunia
and
various
bowel
symptoms
from
diarrhea
to
dyschezia
during
menses,
depending
on
the
locaBon
of
the
deep
lesions.
DR.
KAWITA
BAPAT

13. Types
and
locaBons
of
endometrioBc
lesions
• The
three
primary
types
of
endometriosis
are
• Superficial
Peritoneal
Lesions
• Ovarian
Endometriomas
• Deep
InfiltraBng
Endometriosis
(Die)
•
While
all
three
types
of
lesions
are
associated
with
chronic
pelvic
pain,
the
locaBon
and
extent
of
lesions
correlate
poorly
with
the
locaBon
and
severity
of
experienced
pain.
DR.
KAWITA
BAPAT

14. Clinical
diagnosis
• Endometriosis
Has
Been
Suspected
• Mostly
With
Menstrual-­‐associated
Cyclic
Pain.
• Such
Cyclic
Pain
Is
Not
Pathognomonic
For
Endometriosis
• D/D
With
Fibroids
And
Adenomyosis
May
Also
Have
Dysmenorrhea.
• Furthermore,
Endometriosis
Have
• Non-­‐menstrual
Chronic
Pelvic
Pain
• Complaining
Of
Pain
At
Other
Predictable
Times
Of
Their
Menstrual
Cycle,
Such
As
At
OvulaBon.
• May
Also
Have
Dyspareunia
• Bowel
Bladder
Pain
• Chronic
FaBgue
DR.
KAWITA
BAPAT

15. Burden
of
Endometriosis
• Affects
upto
10%
of
women
• 50%
in
women
with
dysmenorrhea
• 75%
in
women
with
pelvic
pain
• 20-­‐40%
in
women
with
subferBlity
DR.
KAWITA
BAPAT

16. Endometriosis
Management
• Shrouded
in
controversy
• UnsaBsfactory
outcome
• Recurrence
DR.
KAWITA
BAPAT

17. Endometriosis
• The
principal
manifestaBons
• Pelvic
pain
• InferBlity
• Medical
treatments
of
endometriosis
have
focused
on
the
hormonal
alteraBon
of
the
menstrual
cycle
in
an
a`empt
to
produce
a
– Pseudo-­‐pregnancy
– Pseudo
menopause
– Chronic
anovulaBon
Expert Opin. Pharmacotherapy (2003) 4(1),pp 67 - 82
DR.
KAWITA
BAPAT

18. Pelvic
Pain/Dysmenorrhoea
• Empirical
Treatment
– Analgesics
(NSAID,
COX
2
inhibitors)
– COC
Pills
– Progestogens
• If
empirical
treatment
fails,
consider
laparoscopy
ESHRE
2014
DR.
KAWITA
BAPAT

19. Endometriosis
Management
:
Aim
• Complete
resoluBon
of
endometriosis
is
not
yet
possible
and
current
therapy
has
three
main
objecBves:
– To
reduce
pain
– To
increase
the
possibility
of
pregnancy
– To
delay
recurrence
for
as
long
as
possible
Hum
Reprod.
Vol.
18,
No.
2,
pp.
329–348,
2004
DR.
KAWITA
BAPAT

20. Medical
Management
:
When?
• Frequently,
medical
treatment
is
combined
with
surgery
to
produce
opBmal
results
• Expert
Opin.
Pharmacotherapy
(2003)
4(1),pp
67
-­‐
82
DR.
KAWITA
BAPAT

21. Medical
Management
:
When?
• Treatment
with
danazol
or
GnRH
agonist
can
be
used
to
shrink
endometrioBc
implants
pre-­‐operaBvely,
making
it
easier
to
achieve
complete
resecBon
of
implants
by
laparoscopy
• Medical
treatment
can
also
be
given
a^er
conservaBve
surgery
to
improve
paBent
outcomes.
• Expert
Opin.
Pharmacotherapy
(2003)
4(1),pp
67
-­‐
82
DR.
KAWITA
BAPAT

22. • In
order
to
obtain
opBmum
results,
treatment
must
be
individualized
and
take
into
account
the
therapeuBc
goals,
•
the
nature
and
extent
of
the
disease
and
paBent
tolerability
of
side
effects
• The
efficacy
of
medical
and
surgical
treatment
of
endometriosis-­‐associated
inferBlity
and
pelvic
pain
is
a
source
of
ongoing
controversy
DR.
KAWITA
BAPAT

23. TherapeuBc
Agents
• Pain
relievers:
NSAIDs
––
AnB-­‐inflammatory
• Pseudopregnancy
inducers:
– Progesterones
–
MPA
oral/
depot
– Dydrogesterone,
– Dienogest
– Cocs
– LNG-­‐IUS
DR.
KAWITA
BAPAT

24. TherapeuBc
Agents
• ovarian
acBvity
&
menstruaBon
suppressed/
decidualisaBon
• AnBhormone
&
direct
inhibitors:
Danazol,
Gestrinone
-­‐
suppress
steroidogenesisè
hypo-­‐estrogenism
-­‐
antagonist
&
agonist
at
progesterone
receptor
-­‐
displace
testosterone
from
SHBG
&
reduce
SHBG
• Hypoestrogenic
state
inducers:
GnRH
agonists
&
antagonists
DR.
KAWITA
BAPAT

25. Hormonal
Agents
• Progesterones
:
oral/intramuscular
depot
– Bone
loss,
depression,
menstrual
disturbances
• COC
– First
line;
oral/vaginal,
suitable
for
long
term
use
• Danazol
– Use
limited
by
adverse
effects
• GnRHa
– Menopausal
symptoms,
bone
loss
– Use
addback
when
longer
Bme
use
DR.
KAWITA
BAPAT

26. RCOG
Green
Top
Guideline
• If
a
woman
wants
pain
symptoms
suggesBve
of
endometriosis
to
be
treated
without
a
definiBve
diagnosis,
a
therapeuBc
trial
of
a
hormonal
drug
to
reduce
menstrual
flow
is
appropriate
• There
is
inconclusive
evidence
to
show
whether
NSAIDs
(specifically
naproxen)
are
effecBve
in
managing
pain
caused
by
endometriosis
(A)
DR.
KAWITA
BAPAT

27. RCOG
Green
Top
Guideline
• Suppression
of
ovarian
funcBon
for
6
months
reduces
endometriosis-­‐
associated
pain
(A)
• Symptom
recurrence
is
common
following
medical
treatment
of
endometriosis
(B)
DR.
KAWITA
BAPAT

28. RCOG
Green
Top
Guideline
• COC,
danazol,
gestrinone,
MPA
&
GnRHa
are
equally
effecBve
-­‐
adverse
effect
&
cost
differ
• Some
AE
limit
their
long-­‐term
use
&
o^en
produce
poor
compliance
DR.
KAWITA
BAPAT

29. Medical
Management
• Usually
does
not
provide
complete
pain
relief
• Some
women
fail
to
respond
at
all
DR.
KAWITA
BAPAT

30. Medical
Management
• Symptom
recurrence
is
common
following
treatment
(median
Bme
to
recurrence
of
pain
:
Danazol
6.1m,
GnRHa
5.2m)
• Letrozole
may
be
effecBve
but
is
associated
with
significant
bone
loss
– Hormonal
manipulaLon
probably
does
not
affect
any
of
the
primary
biological
mechanisms
responsible
for
the
disease
process
DR.
KAWITA
BAPAT

31. Medical
Management
(RCOG
GTG)
• DuraBon
of
therapy
depends
on
1. Choice
of
drug
2. Response
to
treatment
3. Adverse
effect
profile
• The
LNG-­‐IUS
reduces
pain
from
endometriosis
(A)
• The
use
of
a
GnRHa
+
‘add-­‐back’
(E
+
P)
therapy
protects
against
BMD
loss
at
lumbar
spine
during
treatment
&
for
up
to
6
m
a^er
treatment
(A)
DR.
KAWITA
BAPAT

32. Medical
Management
• There
is
insufficient
evidence
of
benefit
to
jusBfy
the
use
of
preoperaBve
or
postoperaBve
hormonal
treatment
(A)
• Pre-­‐op
hormone
therapy
improves
rAFS
scores
• LNG
IUS,
inserted
at
laparoscopy,
may
reduce
the
risk
of
recurrent
moderate-­‐severe
dysmenorrhoea
at
1
year
• The
ideal
regimen
for
HRT
a^er
bilateral
oophorectomy
is
unclear
• The
role
of
complementary
therapies
in
relieving
endometriosis-­‐associated
pain
is
unclear
DR.
KAWITA
BAPAT

33. SOGC
2010
• Combined
hormonal
contracepBves,
ideally
administered
conBnuously,
should
be
considered
as
first-­‐line
agents.
(I-­‐A)
• AdministraBon
of
progesBn
alone—
oral/IM/SC—may
also
be
considered
as
first-­‐line
therapy.
(I-­‐A)
• A
GnRH
agonist
with
HT
addback,
or
the
LNG-­‐IUS,
should
be
considered
a
second-­‐line
therapeuBc
opBon.
(I-­‐A)
DR.
KAWITA
BAPAT

34. SOGC
2010
• A
GnRH
agonist
should
be
combined
with
HT
addback
therapy
from
commencement
of
therapy
and
may
be
considered
for
longer-­‐
term
use
(>
6
months).
(I-­‐A)
• While
awaiBng
resoluBon
of
symptoms
from
the
directed
medical
or
surgical
treatments,
use
clinical
judgement
in
prescribing
analgesics,
NSAIDs
to
opioids.
(III-­‐A)
DR.
KAWITA
BAPAT

35. COCP
• Limited
evidence
but
widely
used
due
to
1. contracepBve
protecBon,
2. long-­‐term
safety,
3. control
of
menstrual
cycle
4. cost
• Reduces
endometriosis-­‐associated
1. Dysmenorrhoea
2. Dyspareunia
3. Non-­‐menstrual
pain
• May
consider
conBnuous
use
• May
use
vaginal
ring
or
transdermal
patch
DR.
KAWITA
BAPAT

36. Progestogens/
AnB-­‐
progesBns
• All
reduce
endometriosis
associated
pain
• MPA
(oral/depot),
CPA,
Norethisterone,
Danazol,
anB-­‐
progesBns
(Gestrinone)
• LNG
IUS
reduces
endometriosis
associated
pain
DR.
KAWITA
BAPAT

37. GnRHa
• GnRH
reduces
endometriosis-­‐associated
pain
• Limited
evidence
re
duraBon
of
use
&
dosage
• Use
hormonal
add
back
therapy
to
prevent
bone
loss
&
hypoestrogenic
symptoms
(used
up
to
2yrs)
• Add
back
does
not
affect
pain
relief
• No
evidence
on
GnRH
antagonists
• Use
with
cauBon
in
adolescents
&
young
women
DR.
KAWITA
BAPAT

38. GnRHa
(ESHRE
guideline)
• Treatment
for
3
months
with
a
GnRH
agonist
may
be
as
effecBve
as
6
months
in
terms
of
pain
relief
Hornstein
et
al
1995
• Treatment
for
up
to
2
years
with
combined
E
+P
‘add-­‐back’
appears
to
be
effecBve
&
safe
in
terms
of
pain
relief
and
BMD
protecBon
Surrey
&
Hornstein
2002
• However,
careful
consideraBon
should
be
given
to
the
use
of
GnRHa
in
women
who
may
not
have
reached
their
maximum
bone
density
DR.
KAWITA
BAPAT

39. Medical
Management
• Usually
does
not
provide
complete
pain
relief
• Some
women
fail
to
respond
at
all
• Symptom
recurrence
is
common
following
treatment
(Median
Bme
to
recurrence
of
pain
:
Danazol
6.1m,
GnRHa
5.2m)
• Hormonal
manipulaBon
probably
does
not
affect
any
of
the
primary
biological
mechanisms
responsible
for
the
disease
process
DR.
KAWITA
BAPAT

40. Newer
Drugs
• Aromatase
Inhibitors
with/out
progesterones
or
COC
• AnB
TNF
α
• Dienogest
DR.
KAWITA
BAPAT

41. Aromatase
Inhibitors
• Remission
of
pain
• ReducBon
in
visible
endometrioBc
lesions
• Symptoms
recur
soon
a^er
treatment
discontd
• S/E
:
mild
headache,
joint
sBffness/pain,
nausea,
diarrhoea
• Hot
flushes
milder
&
less
frequent
than
GnRHa
• Osteopenia
&
osteoporosis
on
long
term
use
DR.
KAWITA
BAPAT

42. Aromatase
Inhibitors
• Letrozole
2.5mg/d
with
norethindrone/NET/DSG
• Letrozole
2.5mg/d
with
COC
• Anastrozole
1mg/d
with
COC
• Anastrozole
+
Goserelin
vs
Goserelin
alone
:
delayed
symptom
recurrence
DR.
KAWITA
BAPAT

43. Dienogest
• SelecBve
progesterone
receptor
agonist
• 19-­‐nortestosterone
derivaBve
• Oral
agent
used
in
dose
of
2mg
per
day
• Short
plasma
half
life
(about
10
hours)
• High
oral
bioavailablility
(>90%)
• Potent
inhibitory
acBvity
on
the
growth
of
endometrial
Bssue
DR.
KAWITA
BAPAT

44. Dienogest
• Extensively
studied
in
2
clinical
programmes
in
Europe
and
Japan
(treatment
for
24
weeks)
• EffecBvely
alleviates
painful
symptoms
• Improves
indices
of
QOL
• Favourable
safety
and
tolerability
profile
• High
compliance
rate,
low
withdrawal
rate
Köhler
G
et
al;
Int
J
Gynaecol
Obstet.
2010;108(1):21–25.
Momoeda
M
et
al;
Jpn
Pharmacol
Ther.2007;35:769–783.
DR.
KAWITA
BAPAT

45. Dienogest
• Four
RCT
in
Europe
@
2mg/d
• Age
18-­‐45
years
• Significant
reducBon
in
pain
intensity
• Significant
lesion
reducBon
• EffecBve
in
pts
resistant
to
other
progesterone
Int
J
Womens
Health.
2015
Apr
15;7:393-­‐401
Eur
J
Obstet
Gynecol
Reprod
Biol.
2014
Dec;183:188-­‐92
DR.
KAWITA
BAPAT

46. Dienogest
• European
study
laparoscopically
demonstrated
reducBon
of
deposits
in
grade
II-­‐IV
disease
• Direct
comparaBve
study
with
GnRHa
showed
comparable
pain
improvement
in
visual
analog
score
• Non-­‐randomized
study
of
12m
use
(monotherapy)
showed
significant
reducBon
in
dyspareunia
and
non
menstrual
pelvic
pain
&
comparable
result
to
GnRH
agonist
followed
by
dienogest
Dienogest
in
long-­‐term
treatment
of
endometriosis:
Schindler
A
E,
Int
J
Womens
Health.
2011;
3:
175–184.
DR.
KAWITA
BAPAT

47. Dienogest
• EffecBvely
suppresses
ovulaBon
at
2
mg/day
but
non-­‐hormonal
contracepBon
should
be
advised
• Acceptable
agent
for
monotherapy
• Approved
as
monotherapy
agent
in
Europe,
Japan,
Australia
and
Singapore
Dienogest
in
long-­‐term
treatment
of
endometriosis:
Schindler
A
E,
Int
J
Womens
Health.
2011;
3:
175–184.
DR.
KAWITA
BAPAT

48. Dienogest
in
RV
Endometriosis
• 24
week
study
of
25
symptomaBc
women
• Decreased
intensity
of
CPP,
dyspareunia,
dyschezia
• Improved
QoL
&
sexual
life
a^er
6m
treatment
• No
significant
change
in
volume
of
lesion
– Eur
J
Obstet
Gynecol
Reprod
Biol.
2014
Dec;183:188
• EffecBve
in
reducing
pain
in
DIE
(no
reducBon
in
volume
of
nodule)
on
12
m
use
of
Dienogest
-­‐ Leonardo
Pinto
et
al.
Eur
J
Obs
Gyn
Reprod
Biol
2017
DR.
KAWITA
BAPAT

49. Dienogest
vs
Leuprolide
• Equally
effecBve
in
reducing
symptoms
of
dysmenorrhoea,
dyspareunia
&
pelvic
pain
• Minimal
change
in
BMD
• No
hot
flushes
– Strowitzki
et
al.
Hum
Reprod
2010
DR.
KAWITA
BAPAT

50. Dienogest
• Beneficial
effect
on
pain
exceeds
the
period
of
treatment
• E2
levels
maintained
in
low
physiological
levels
• Superior
to
GnRHa
in
BMD
change
(less
bone
loss)
• PotenBal
for
effecBve
long
term
treatment,
mulBcentre
study
(Arch
Gynecol
Obstet.
2012
Jan;
285(1):
167)
• Dienogest
containing
pill
provides
a
long
term
opBon
in
endometriosis
mgmt
with
excellent
bleeding
profile
• D/E2V
comparable
to
GnRHa
in
reducing
recurrence
of
pain
following
laparoscopy
(Acta
Obstet
Gynecol
Scand
2015
Mar
)
• Improves
IVF
success
in
women
with
adenomyosis
&
IVF
failures
(Vartanyan
et
al.
Gynecol
Endocrinol
2015)
DR.
KAWITA
BAPAT

51. Dienogest
• Problem
with
iniBal
bleeding
irregulariBes
(72%),
but
intensity
&
frequency
reduces
on
conBnued
treatment
• Other
S/E–
progesterone
effects
(headache-­‐9-­‐18%,
consBpaBon-­‐10%,
breast
discomfort
5%,
depressed
mood
5%,
acne
5%)
DR.
KAWITA
BAPAT

52. Dienogest
:
How
long?
• 52
wks
@
2mg/d
in
adenomyosis
– Osuga
et
al.
J
Obstet
Gynecol
Res
2017
• EffecBve
&
well
tolerated
on
12
month
use
– Maoirama
et
al.
Arch
Gynecol
Obstet
2017
• Used
for
31
+/-­‐
17m
following
laparoscopy
for
DIE
to
prevent
recurrence
– Yamanaka
et
al.
Eur
J
Obs
Gyn
Reprod
Biol
2017
• EffecBve
in
reducing
pain
in
DIE
(no
reducBon
in
volume
of
nodule)
on
12
m
use
of
Dienogest
-­‐ Leonardo
Pinto
et
al.
Eur
J
Obs
Gyn
Reprod
Biol
2017
DR.
KAWITA
BAPAT

53. Dienogest
:
IndicaBons
• First
line
management
• Prolonged
therapy
• Post
op
adjuvant
• RV
endometriosis
for
pain
relief
• Secondary
prevenBon
• Recurrence
• Adenomyosis
DR.
KAWITA
BAPAT

54. Surgical
Management
DR.
KAWITA
BAPAT

55. Surgery
for
Pain
• If
endometriosis
detected
at
laparoscopy,
treat
• Laparoscopy
&
laparotomy
equally
effecBve
• Laparoscopy
associated
with
– Less
pain
– Shorter
hospital
stay
– Quicker
recovery
– Be`er
cosmesis
– Recurrent
surgery
–
less
morbidity
DR.
KAWITA
BAPAT

56. Surgical
Treatment
• Excision
or
ablaBon
(by
laser
or
cautery)
of
endometrioBc
implants
• Surgical
excision
of
endometriosis
results
in
improved
pain
relief
and
quality
of
life
a^er
6
months
compared
with
diagnosBc
laparoscopy
alone
• However,
there
is
a
significant
recurrence
rate
of
pain
DR.
KAWITA
BAPAT

57. Surgical
Treatment
Peritoneal
Endometriosis
Laparoscopy
aims
to
• remove
all
visible
areas
of
pelvic
endometriosis
&
• restore
anatomy
by
division
of
adhesions
DR.
KAWITA
BAPAT

58. Surgical
Treatment
:
Success
• Surgery
despite
its
proven
efficacy
is
challenged
by
high
recurrence
rate
– 40–45%
recurrence
rate
within
5yrs
post-­‐
operaBvely
– In
case
of
endometriomas,
symptoms
(pain
or
inferBlity)
recur
in
76%
of
paBents
• Even
a^er
curaBve
surgery,
rates
of
recurrence
are
as
great
as
5–10%.2
DR.
KAWITA
BAPAT

59. Post
op
Treatment
(ESHRE)
• Treatment
with
danazol
or
a
GnRH
agonist
for
6
m
a^er
surgery
reduces
endometriosis
associated
pain
&
delays
recurrence
at
12
and
24
months
compared
with
placebo
&
expectant
management
• Post-­‐op
treatment
with
a
COC
is
not
effecBve
– Telimaa
et
al.,
1987;
Parazzini
et
al.,
1994;
Hornstein
et
al.,
1997;
Bianchi
et
al.,
1999;
Morgante
et
al.,
1999;
Vercellini
et
al.,
1999b;
Muzii
et
al.,
2000;
Busacca
et
al.,
2001
DR.
KAWITA
BAPAT

60. DNG
vs
GnRHa
post
op
• Post
Laparoscopy
for
endometriosis
women
randomised
to
Dienogest
2mg/d
for
6m
or
monthly
Goserelin
x
6
• Those
who
refused
post
op
adjuvant
observed
• Recurrence
rates
&
symptom
relief
similar
in
both
treatment
groups,
be`er
than
no
treatment
• Less
S/E
in
Dienogest
group
• Takesu
et
al.
J
Obstet
Gynecol
Res
2016
DR.
KAWITA
BAPAT

61. Secondary
PrevenBon
• Post
op
adjuvant
hormonal
therapy
can
be
prescribed
for
contracepBon/secondary
prevenBon
• Long
term
post-­‐op
hormonal
treament
(>6months)
aimed
at
secondary
prevenBon
• Secondary
prevenBon
:
COCP,
LNG
IUS,
DNG
• LNG
IUS,
inserted
at
laparoscopy,
may
reduce
the
risk
of
recurrent
moderate-­‐severe
dysmenorrhoea,
but
does
not
reduce
endometrioma
recurrence
– Chen
et
al.Am
J
Obstet
Gynecol
2017
DR.
KAWITA
BAPAT

62. Take
Home
Messages
• Role
of
medical
mgmt
in
endometriosis
is
limited
• All
agents
are
equally
effecBve/ineffecBve
for
pain
relief
• LNG
IUS
is
effecBve
for
post-­‐op
pain
relief
• Pre-­‐op
GnRHa
therapy
improves
rAFS
scores
• Post-­‐op
GnRHa/Danazol
delays
recurrence
&
reduces
pain
• AE
limit
the
use
of
Danazol
• Dienogest
is
an
effecBve
opBon
for
medical
management
as
first
line
or
post
operaBve,
and
has
the
potenBal
for
long
term
use
DR.
KAWITA
BAPAT

63. Thank
you
Treatment
of
endometriosis
needs
to
be
individualised
CombinaLon
of
surgical
&
medical
treatment
is
the
best
opLon
in
most
situaLons
DR.
KAWITA
BAPAT

64. Post
op
Treatment
(ESHRE)
• Treatment
with
danazol
or
a
GnRH
agonist
for
6
m
a^er
surgery
reduces
endometriosis
associated
pain
&
delays
recurrence
at
12
and
24
months
compared
with
placebo
&
expectant
management
• Post-­‐op
treatment
with
a
COC
is
not
effecBve
– Telimaa
et
al.,
1987;
Parazzini
et
al.,
1994;
Hornstein
et
al.,
1997;
Bianchi
et
al.,
1999;
Morgante
et
al.,
1999;
Vercellini
et
al.,
1999b;
Muzii
et
al.,
2000;
Busacca
et
al.,
2001
DR.
KAWITA
BAPAT

65. DNG
vs
GnRHa
post
op
• Post
Laparoscopy
for
endometriosis
women
randomised
to
Dienogest
2mg/d
for
6m
or
monthly
Goserelin
x
6
• Those
who
refused
post
op
adjuvant
observed
• Recurrence
rates
&
symptom
relief
similar
in
both
treatment
groups,
be`er
than
no
treatment
• Less
S/E
in
Dienogest
group
• Takesu
et
al.
J
Obstet
Gynecol
Res
2016
DR.
KAWITA
BAPAT

66. Secondary
PrevenBon
• Post
op
adjuvant
hormonal
therapy
can
be
prescribed
for
contracepBon/secondary
prevenBon
• Long
term
post-­‐op
hormonal
treament
(>6months)
aimed
at
secondary
prevenBon
• Secondary
prevenBon
:
COCP,
LNG
IUS,
DNG
• LNG
IUS,
inserted
at
laparoscopy,
may
reduce
the
risk
of
recurrent
moderate-­‐severe
dysmenorrhoea,
but
does
not
reduce
endometrioma
recurrence
– Chen
et
al.Am
J
Obstet
Gynecol
2017
DR.
KAWITA
BAPAT

67. Ovarian
Endometrioma
• Ovarian
endometrioma
>
3cm
should
be
operated
if
pain
or
subferBlity
• AspiraBon
not
recommended
• AblaBon/Drainage
&
CoagulaBon
(aspiraBon/irrigaBon/diathermy)
:
risk
of
incomplete
surgery
(early
recurrence)
• Excison/Cystectomy
preferable
(less
recurrence)
• Ovarian
cancer
in
endometrioma
<1%,
send
histology
DR.
KAWITA
BAPAT

68. Surgical
Treatment
Peritoneal
Endometriosis
Laparoscopy
aims
to
• remove
all
visible
areas
of
pelvic
endometriosis
&
• restore
anatomy
by
division
of
adhesions
Ovarian
endometrioma
Two
laparoscopic
techniques
• excision
(stripping)
technique
• ablaBon
of
the
cyst
wall
DR.
KAWITA
BAPAT

69. Endometrioma
:
Excision
vs
AblaBon
• Less
pain
with
cystectomy
• Less
recurrence
risk
(6-­‐8%
vs
12-­‐23%)
• Less
recurrence
of
dysmenorrhoea,
dyspareunia,
non-­‐menstrual
pelvic
pain
• More
reducBon
of
ovarian
reserve
• Combined
excision/ablaBon
:
Aspirate,
irrigate,
enucleate
Bll
reach
hilum,
then
cut
cyst
wall
with
scissors
and
vaporize
at
hilum
with
diathermy/laser
DR.
KAWITA
BAPAT

70. Surgical
Treatment
:
Success
• Surgery
despite
its
proven
efficacy
is
challenged
by
high
recurrence
rate
– 40–45%
recurrence
rate
within
5yrs
post-­‐
operaBvely
– In
case
of
endometriomas,
symptoms
(pain
or
inferBlity)
recur
in
76%
of
paBents
• Even
a^er
curaBve
surgery,
rates
of
recurrence
are
as
great
as
5–10%.2
DR.
KAWITA
BAPAT

71. DR.
KAWITA
BAPAT