This document discusses endometriosis, including its definition, theories of pathogenesis, risk factors, clinical presentation, investigations, staging, and management approaches. It provides an overview of endometriosis, describing it as the presence of functioning endometrial tissue outside the uterine cavity, with a reported incidence of 20-25% in the reproductive age group. Theories discussed to explain its pathogenesis include retrograde menstruation, coelomic metaplasia, and metastasis. Hormonal factors, immunology, and genetics are also implicated in its development. Staging is typically done using the revised American Fertility Society classification system. Management involves a tailored approach considering symptoms, fertility goals, and side effects of treatments.
Adenomyosis is a benign disease of the uterus characterized by ectopic endometrial glands and stroma within the myometrium.
It is associated with myometrial hypertrophy and may be either diffuse or focal.
Adenomyosis is a benign disease of the uterus characterized by ectopic endometrial glands and stroma within the myometrium.
It is associated with myometrial hypertrophy and may be either diffuse or focal.
Understand the history and pathophysiology of endometriosis
Understand the critical need for timely diagnosis and effective intervention
Understand the considerable effects and cost burdens of this chronic disease and employ best-practice techniques to mitigate them
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
Understand the history and pathophysiology of endometriosis
Understand the critical need for timely diagnosis and effective intervention
Understand the considerable effects and cost burdens of this chronic disease and employ best-practice techniques to mitigate them
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
Endometriosis An Enigmatic Disease, DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyo...Lifecare Centre
ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE
Endometriosis: The Pain That Keeps on Giving
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”
Endometriosis still an enigmatic disease dr. sharda jainLifecare Centre
ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE : Introduction DR. SHARDA JAIN DR. JYOTI AGARWAL
DR. JYOTI BHASKER
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”
ENDOMETRIOSIS: THE BITTER TRUTH
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
Endometriosis :An Overview
Presented in Endometriosis update in Delhi June (2016) Hotel Leela
EB Guidelines
RCOG: Evidence-based Clinical, 1999
Endometriosis and infertility. ASRM, 2004.
ACOG. Endometriosis in adolescents, 2005.
ESHRE guideline for the diagnosis and treatment of endometriosis, 2005.
Endometriosis and infertility. ASRM, 2006.
Endometriosis: diagnosis and management.
Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis,2014.
What to Expect if You’ve Been Diagnosed with Placenta PreviaMiami ObGyns
www.miamiobgyns.com/blog/diagnosed-placenta-previa/
If you’ve been diagnosed with Placenta Previa you are sure to have many questions about the causes, risks and treatments. Here’s what to expect...
Benign ovarian masses include functional cysts and tumors; most are asymptomatic.Most functional cysts and benign tumors are asymptomatic. Sometimes they cause menstrual abnormalities. Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis, particularly when they rupture. Occasionally, severe abdominal pain results from adnexal torsion of a cyst or mass, usually > 4 cm. Treatment varies depending on the patient's reproductive status.
Definition
Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis.
It is a benign but it is locally invasive.
Prevalence
The real one is due to delayed marriage, postponement of first conception and adoption of small family norm.
The apparent one is due to increased use of diagnostic laparoscopy as well as hightened awareness of this disease complex amongst the gynecologists
Sites
Abdominal: Usually confined to the abdominal structures below the level of umbilicus.
Extra-abdominal: Common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix.
Remote
Pathology
Naked Eye Appearance: The appearance of the lesion depends on the organs involved, extent of lesion and reaction of the surrounding tissues.
Pelvic endometriosis: Small black dots, called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas.
Fibrosis and scarring
Symptoms
Dysmenorrhea (70%)
Abnormal menstruation (20%)
Infertility (40–60%)
Dyspareunia (20–40%)
Chronic Pelvic Pain
Abdominal Pain
Urinary— frequency, dysuria, back pain or even hematuria.
Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena.
Chronic fatigue, perimenstrual symptoms (bowel, bladder).
Hemoptysis (rarely), chest pain.
Surgical scars—cyclical pain and bleeding.
Examination
Abdominal palpation
A mass may be felt in the lower abdomen arising from the enlarged tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility.
Pelvic Examination
Pelvic tenderness, nodules in the pouch of Douglas, nodular feel of the uterosacral ligaments, fixed uterus or unilateral or bilateral adnexal mass of varying sizes
Diagnosis
Bichemical parameters:
Serum CA 125
Monocyte Chemotactic Protein (MCP-1)
Imaging:
TVS - ovarian endometriomas
Endorectal USG - Rectosigmoid endometriosis
MRI - deep infiltrating endometriosis.
Colonoscopy, rectosigmoidoscopy and cystoscopy
Differential Diagnosis
Chronic pelvic infection / symptomatic endometriosis. Laparoscopy is helpful in actual diagnosis.
Ovarian endometrioma / benign ovarian tumor / malignant ovarian.
Ultrasonography or Laparoscopy
Rupture of the chocolate cyst / torsion or rupture of the ovarian tumour, disturbed ectopic pregnancy, appendicitis or diverticulitis.
Complications
Endocrinopathy
Rupture of chocolate cyst
Infection of chocolate cyst
Obstructive features:
Intestinal obstruction
Ureteral obstruction → hydroureter
hydronephrosis → renal infection
Endocrinopathy in Endometriosis
Corpus luteum insufficiency
Luteolysis due to ↑ PGF.
Luteinized unruptured follicle (LUF)
Anovulation
Elevated prolactin level
Double LH peak.
Staging
Endometrios is should be staged appropriately.
To predict prognosis.
To choose therapy.
To evaluate the treatment protocol.
The stage is determined by adding specific points given to each.
Endometriosis is known to have a remarkably negative effect on the Quality of Life of the women. Surgery is considered when medical therapy is unsuccessful or in the setting of infertility. A high recurrence rate is reported in advanced stages of endometriosis. Thus, Complete excision and prevention of recurrence is particularly important.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
Endometriosis
1. Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
2. Presence of active functioning
endometrial implants outside its normal
place i.e uterine cavity
Incidence:20-25% in reproductive age
group
3. Implantation theory :
Sampson's pioneering work in 1922 attributed endometriosis
to reflux of menstrual endometrium through the fallopian
tubes. Occurrence of scar endometriosis following classical
caesarean section, hysterotomy, myomectomy and episiotomy
further supports this view.
Coelomic metaplasia theory :
Meyer and Ivanoff (1919) propounded that endometriosis
arises as a result of metaplastic changes in embryonic cell
rests of embryonic mesothelium. Hormonal stimulation of
Embryologically similar tissues to the Mullerian ducts.
Metastatic theory :
Suggested by Halban et al. (1924) that embolization of
menstrual fragments through vascular or lymphatic
channels, explain its occurrence at less accessible sites
like the umbilicus, pelvic lymph nodes, ureter,
rectovaginal septum, bowel wall, and remote sites like
the lung, pleura, endocardium and the extremities.
4. Hormonal influence : The initial genesis of
endometriosis, its further development depends on the
presence of hormones, mainly oestrogen. Pregnancy
causes atrophy of endometriosis through high
progesterone level. Regression also follows oophorectomy
and irradiation. Endometriosis is rarely seen before
puberty and it regresses after menopause. Hormones with
antioestrogenic activity also suppress endometriosis and
are used therapeutically.
Immunological factor : The peritoneal fluid in
endometriosis shows the presence of macrophages and
natural killer (NK) cells. Impaired T cell and NK cell activity
and altered immunology.
Other factors : Genetic - familial tendency reported in
15% cases, multifactorial, vaginal or cervical atresia which
encourage retrograde spill. Prostaglandins.
9. Early lesions appear papular and red vesicles are filled with
haemorrhagic fluid with surrounding flame-like lesions.
Over time, these vesicles change colour and endometriotic
areas appear as dark red, bluish or black cystic areas
adherent to the site. Scarring in the endometriosis makes it
puckered. Atypical lesions such as non-pigmented areas or
yellowish-white thick plaques have been noticed, which are
healed lesions. Powder burnt areas are the inactive and old
lesions seen scattered over the pelvic peritoneum.
Chocolate cysts of the ovaries represent the most important
manifestation of endometriosis. To the naked eye, the
chocolate cyst shows obvious thickening of tunica albuginea,
and vascular red adhesions are well marked on the
undersurface of the ovary. The inner surface of the cyst wall
is vascular and contains areas of dark brown tissue. The
chocolate cyst lies in the ovary and adherent to lateral pelvic
wall.
13. On History
Common symptoms :
Chronic pelvic pain, worsening dysmenorrhea,
acquired dyspareunia, infertility, premenstrual
spotting, dyschezia.
Risk factors :
First degree relative affected, short menstrual
cycles, long duration of menstrual flow, low parity,
infertility, fair complexioned, reproductive tract
14. Examination
On bimanual pelvic examination, fixed retroverted uterus,
bilateral pelvic tenderness, fixed or enlarged ovaries and painful
uterosacral nodularity.
Deeply infiltrating nodules are most reliably detected when
clinical examination is performed during menstruation.
Adenomyotic uterus is seldom > 12 weeks, soft, smooth & tender
in contrast to fibroid uterus. Isolated adenomyoma can be
differentiated by presence of localised tenderness
15. Investigations
Laparoscopy: Gold standard It should not be
performed within 3 months of hormonal
treatment to prevent under diagnosis
Ultrasound: Ultrasound has a limited role,
however the addition of colour doppler claims
to increase the sensitivity to 91.8%, specificity
of 91.3%
MRI –useful
Ca 125-Maybe elevated in severe
16.
17. Histological Confirmation:
Visual inspection is usually adequate but
histological confirmation of at least one lesion is
ideal.
In cases of ovarian endometrioma >3 cm in
diameter and in deeply infiltrating disease,
histology is a must to rule out malignancy.
18. Laparoscopy (Sensitivity : 97%, Specificity 95%)
Types of lesions on laparoscopy:
Powder burn or black lesions
White opacified peritoneum
Glandular excrescences
Flame like red lesions
Peritoneal pockets or windows
Clear vesicles
Yellow brown patches
Unexplained adherence of ovary to peritoneum of
ovarian fossa
Encysted collection of thick chocolate coloured or
tarry fluids
Adhesions to posterior lip of broad ligaments/other
19.
20.
21. LAPROSCOPIC IMAGES :
A OLD ENDOMETRIOSIS (Blue/Grey) B OLD ENDOMETRIOSIS (Red)
C OLD ENDOMETRIOSIS (Brown) D ACTIVE ENDOMETRIOSIS (Black)
22.
23.
24. Sonographic Features :
Endometritic cysts (oval or round)- capsulated, fine
homogeneous, uniform, granular echoes,
anechoic, single or multiple, unilateral or bilateral
On Doppler: no vascularity within the mass
Ovarian adhesions to uterus
Free floating fimbria on sonosalpingography
25. Several Proposed Schemes
Revised AFS System: Most Often Used
Ranges from Stage I (Minimal) to Stage IV (Severe)
Staging Involves Location and Depth of Disease,
Extent of Adhesions
26.
27. Revised American Fertility Society Classification of endometriosis 1985
Patient's name Age Date
Stage I (Minimal) Score 1-5 Laparoscopy/Laparotomy/Photography
Stage II (Mild) Score 6-15 Recommended treatment
Stage III (Moderate) Score 16-40
Stage IV (Severe) Score > 40
Total Prognosis
Peritoneal endometriosis <1 cm 1-3 cm >3 cm
Superficial 1 2 4
Deep 2 4 6
Ovarian endometriosis <1 cm 1-3 cm >3 cm Right/Left side separate points
Superficial 1 2 4
Deep 4 16 20
cul-de-sac obliteration Partial Complete
4 40
Ovarian adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
Flimsy 1 2 4
Dense 4 8 16
Tubal adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
Flimsy 1 2 4
Dense 4 8 16
29. Recognize Goals:
– Pain Management
– Preservation / Restoration of Fertility
Discuss with Patient:
– Disease may be Chronic and Not
Curable
– Optimal Treatment Unproven or
Nonexistent
30. Management of Endometriosis must be ‘tailor
made’ taking into account, patients profile,
presenting symptoms, impact of the disease and
effects of treatment on day to day life.
31. Empirical treatment of pain symptoms without
definitive diagnosis of endometriosis, a
therapeutic trial of hormonal drug to reduce
menstrual flow is appropriate.
Medical Therapy for endometriosis can be used
either as primary therapy or in conjunction with
surgery preoperatively or postoperatively-
Sandwich Therapy
32. How effective are NSAIDS in treating
endometriosis associated pain?
There is inconclusive evidence to show whether
NSAIDS are effective in managing pain caused by
endometriosis
Advantages:
Not operator dependent
Less expensive
No surgical/anesthetic risk
No post- op adhesion formation
Disadvantages:
Prolonged treatment
Gastric ulceration
Temporary relief
33. • GnRH analogues: creates a pseudo menopausal
state
• Advantages:
• Reduction in pelvic vascularity and inflammation
• Reduction in size and activity of endometriotic
implants
• Reduction in ovarian cyst diameter
• Reduction in cyst wall diameter
• Disadvantages:
• Hypoestrogenic state
• Bone loss(can be controlled by add back regimen-
35. Progesterone:- Pseudo pregnancy (Kristner’s
Regime) state.
Acts by decidualisation and atrophy of the estrogen
dependent endometriotic foci
Common progesterones : Medroxy progesterone
acetate, norethesiterone, dydrogesterone,
DMPA - cost effective, readily available, 66%
complete resolution
LNG-IUS(Mirena) reduces endometriosis associated
pain(symptom control over 3 years)
Side effects : Irregular Bleeding, weight gain, fluid
retention, breast tenderness, mood changes,
36. Gestrinone: Androgenic, progestogenic and
antiestrogenic
Dosage: 1-25-2-5mg biweekly
Side effects : similar to danazol
37. Combined OC Pills:
To reduce the frequent prolonged bleeding not
recommended in infertile endometriotic women.
However COCs are the only effective prophylaxis
in against endometriosis.
38. RU 486: antiprogestogenic activity with minimal or
no other endocrinologic effects
Aromatase Inhibitor: Acts on the diseased
endometriotic implants to decrease local oestrogen
production-to inhibit the growth of implants.
Interferons: combination with GnRH have resulted
in higher cumulative pregnancy rates and monthly
fecundity rates
SERMs: Selective antiestrogenic activity on the
endometrium, agonist activity on bones and
39. 1997; Rice, 2002; Valle et al., 2003; Donnez et al., 2004;
Crosignani et al., 2005; Schlaff et al., in press)
Agent Dose Route Dosing frequency Common side effects
Combined 30–35 μg Oral Daily (cyclic or continuous) Irregular bleeding,
oral ethinyl weight gain, bloating,
contraceptives estradiol, breast tension and
plus headache
progestin
Danazol 400–800 Oral Daily (duration limited to Androgenic/anabolic
mg 6 months by side effects) (weight gain, fluid
retention, breast
atrophy, acne, oily
skin,
hot flashes and
hirsutism)
GnRH (Duration limited to 6
agonists months
due to BMD effects)
Leuprolide 1mg/day SC daily Hypoestrogenic (hot
injection flashes, vaginal
dryness, emotional
lability, loss of libido
and BMD decline)
Leuprolide 3.75mg IM Monthly
depot 11.75mg IM Every 3 monthly
40. Agent Dose Route Dosing frequency Common side effects
Triptorelin 3mg IM Monthly
Triptorelin 11.25mg IM Every 3 monthly
depot
Goserelin 3.6mg SC Monthly
Buserelin 300- Intranasal Tds
400µg
Naserelin 200- Intranasal Bd
400µg
Progestins Irregular bleeding
bloating weight gain
and edema
Dydrogestero 60mg Oral 12 days per cycle
ne
Gestrinone 2.5-5mg Oral Daily
Megestrel 40mg Oral Daily
acetate
Norethindrone 5mg Oral Daily
acetate
MPA 30mg Oral daily
DMPA-150 150mg IM Every 3 months
41. Indications:
Mild Endometriosis associated with
infertility
Endometrioma >4 cm in diameter
Endometriosis of rectovaginal septum or
rectal wall
Failed Medical therapy
Intolerable side effects of medical therapy
Endometriosis with other surgically
correctable infertility factors
42. Pre operative assessment: MRI or Ultrasound with
or without IVP, Barium enema, sigmoidoscopy
Preoperative and post-op medical management:
GnRh-a like goserilin for 3 months preoperatively
reduces the size and AFS score.
Postoperative therapy gives longer period of
remission.
43. Primary operation is the best opportunity
Best outcome by excision of the lesion
Complete excision has lowest recurrence of
19%
Adhesions require excision rather than
simple division
44. Electrosurgical instruments are used for excision
of endometriotic focii pelvic peritoneum, however
the depth of dissection is unpredictable & hence
damage to gut.
Sophisticated energy sources available are:
1. Carbon dioxide or Nd YAG laser: Allows
vaporisation; excision; high cost
2. Harmonic scalpel: Ultrasound mechanical source,
for cutting and coagulation
3. Argon beam: for widespread superficial lesion
4. Helica thermal coagulator: effective in
vaporisation with risk of thermal damage.
45. Surgery when pain relief is the priority:
Early stage disease: LUNA along with ablation of
endometrial deposits improves outcome
Moderate to severe disease: Removal of the entire
lesion recommended
Endometrioma:
1. For large unilateral endometrioma-
salpingoopherectomy of the affected side;
2. Bilateral large endometrioma: <40years: ovarian
tissue to be conserved as far as possible
3. Insufficient evidence to justify use of pre op or
post op hormones
4. HRT recommendation after bilateral
salpingooherectomy is controversial
46. Surgery when infertility is the priority
Early stage disease: Laparoscopic excision or
ablation with adhesiolysis
Moderate to severe endometriosis: role of surgery
is uncertain(overactive excision may reduce
fertility)
Endometrioma: laparosopic cystectomy better
than drainage and coagulation.
Post op hormonal treatment has no beneficial effect
on pregnancy rates after surgery
Tubal flushing improves pregnancy rates.
47.
48. Treatment with IUI improves fertility in minimal to
mild endometriosis
IVF appropriate especially when tubal function is
compromised, if there is male factor infertility
and/or other treatments have failed.
Treatment with GnRH agonists for 3-6months
before IVF increases the rate of clinical
pregnancies
Laparoscopic ovarian cystectomy is recommended
for endometriomas >4cm in diameter.