ENDOMETRIOSIS: THE PROBLEM STATEMENT: dr. sharda jain+ENIGMATIC DISEASE ,Biggest Gynaecologist’s dilemma Epidemiology RISK FACTORS (Odukoya & Cooke, 1996) ,Pathogenesis Symptoms Ovarian Endometrioma,Magnetic Resonance Imaging????Treatment : Consideration

1. ENDOMETRIOSIS:
THE PROBLEM STATEMENT
DR. SHARDA JAIN
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar
…Caring hearts, healing hands

2. ENDOMETRIOSIS STILLAN
ENIGMATIC DISEASE
…Caring hearts, healing hands
The journey of life mysterious, but the disease
endometriosis is more mysterious than life
itself!
All aspects of endometriosis are still an
enigma, right from incidence, diagnosis and
management.

3. “Endometriosis remained a riddle wrapped
in a mystery …even for these Celebrities
who could buy anything on earth ”
…Caring hearts, healing hands

4. •Diagnostic Dilemma
•Debilitating Disease
•Progressive Disease
•Disease with “No Cure”
*H/O Multiple Operations
Biggest Gynaecologist’s
dilemma

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. 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. March
is
Endometriosis
Awareness
Month

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. • Age: Problem of reproductive period
• True Incidence Unknown: ?
• Does NOT Discriminate by Race.
• Histology: Endometrial Glands with Stroma
+/- Inflammatory Reaction.
• Hereditary (↑↑ among sisters)..15%.
Epidemiology

10. Delay to Diagnosis
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. PREVALENCE
•10..20%
Prevalence is higher in women with
• Dysmenorrhea : upto 60%
• Dyspareunia : upto 44%
• Pelvic Pain : upto 80%

14. 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

15. 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 ?

16. Pathogenesis
I- IMPLANTATION theory:
Retrograde mentruation.
II .Embolisation
Theory..Vascular &
lymphatic. Mechanical.
III-METAPLASIA
Theory… In situ
development: Coelomic
metaplasia.
IV- Immunological.
V- Composite.

17. Endometriosis is said to be
Estrogen dependent .
It is one of the major causative
factors in the development of
endometriosis.
Pathogenesis ??

18. Excess Estrogen stimulates
Inflammation
Invasion
Angiogenesis
Cell Proliferation
Adhesions Pain

19. 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.

20. 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%.

21. 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.

22. REVISED AFS (1985)
• Stage I (minimal) 1 – 5.
• Stage II (mild) 6 – 15.
• Stage III (moderate) 16 – 40.
• Stage IV (severe) > 40.

23. Symptoms
Infertility 40 % Dysmenorrhoea 60 %
Chronic
Pelvic
Pain 80%
Pain
Premenstrual
Intramenstrual
Postmenstrual
100%
Dyspareunia 45 %
Absolutely asymtomatic….to most miserable

24. IN WOMEN OF REPRODUCTIVE AGE WITH
NON-GYNAECOLOGICAL CYCLICAL SYMPTOMS
• Dyschezia
• Dysuria
• Haematuria
• Rectal bleeding
• Shoulder pain.

25. 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.Kissing Ovarian cysts may be detected.
Signs

26. • It should include both-
• Per Abdomen
• Per Speculum
• Per Vaginum
• Highest predictive value
• -- Menstruation
In all women suspected of
endometriosis

27. 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

28. 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

29. Consider Ovarian Endometriosis
Adnexal Masses
Chocolate cyst speak stage three /four
disease

30. Be Obsessed with Endometriosis
• In women suspected of the disease
even if the clinical examination is
NORMAL

31. 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%)

32. Ovarian Endometrioma
Perform TVS
Classical Endometrioma

33. Magnetic Resonance Imaging
????
• Clinicians should be aware that the
usefulness of magnetic resonance
imaging (MRI)
to diagnose Peritoneal Endometriosis
is not well established

34. Biomarkers ????
Clinicians are recommended not to use
biomarkers to diagnose endometriosis.
• and/or immunological biomarkers, including
CA-125, in plasma, urine or serum
• CA 125 is mainly used in followup of case

35. Treatment : Consideration
• Age.
• Symptoms.
• Stage.
• Infertility.

36. 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

37. When is Medical Treatment
Required ?
• First line treatment with chocolate cyst
inAdolecents /young women?
• 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

38. ESHRE
guidelines
2014
Best so far
For Treatment
Will answer all your queries

39. 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

40. Treatment..Philosophy
ESHRE 2008
• Endometriosis should be viewed as a
chronic disease that requires a life –long
management plan with the goal of
maximizing the use of medical
treatment and avoid repeated surgical
procedures.

41. Treatment
• Laparoscopy remains that cornerstone of accurate
diagnosis of endometriosis
• Harmonal treatments does not work for deep
infiltrative disease, adenomyosis & scar
endometriosis
• In women with symptoms of pelvic pain, visible
endometriosis observed during surgery should be
treated.
• Surgical treatment for endometriosis, followed by
medical therapy, offers longer symptom relief than
surgery alone

42. ●●● ORAL Medication
Dienogest Elagolix
● Effective ● Seems effective
● Up to 2 yrs ● Up to 6 month
● Menstrual ● BMD Effected
Irregularities ++ ● Not reported
● Contraindicated ● NO contraindications
Liver/ CVS

43. Endometriosis & IVF
• It is preferable not to cauterize
ovarian tissue if IVF or ICSI is
indicated for fear of destruction of
ovarian tissues.
–Should be referred for IVF early than
Late
• The presence of endometriosis does
not generally impair the results of
IVF but it increases the risk of
infection.

44. Take Home Message
• It seems that the age of injections is
fading away
• Orally administered medications for
endometriosis is now a reality
• Individualisation of Treatment is
the key.

45. • 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

46. 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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