This document discusses the management of endometriosis. It defines endometriosis as tissue similar to the endometrium found outside the uterus, causing inflammation. Common symptoms include severe menstrual pain, pain during or after sex, chronic pelvic pain, and infertility. Diagnosis is typically via laparoscopy, which allows visualization and staging of lesions. Treatment involves surgery to remove lesions and adhesions or drain endometriomas, along with medical therapy using hormones to suppress the endometrial tissue. Goals of treatment are pain relief and improving fertility.
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
tubal factor is almost 30% of all female infertility causes.Hence evaluation of tubes is usulally the first of the testings.
this presentation evaluates all the methods for evaluation of fallopian tubes
Menstrual irregularities are the problems with a girl's normal monthly menses. For example, missed periods, have them too frequently, having painful periods, or have excessively heavy flow. Menstrual irregularities can sometimes be a sign of an underlying health problem.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
tubal factor is almost 30% of all female infertility causes.Hence evaluation of tubes is usulally the first of the testings.
this presentation evaluates all the methods for evaluation of fallopian tubes
Menstrual irregularities are the problems with a girl's normal monthly menses. For example, missed periods, have them too frequently, having painful periods, or have excessively heavy flow. Menstrual irregularities can sometimes be a sign of an underlying health problem.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Endometriosis and fertility how and when to treatDr Aditya Keya
Endometriosis can influence fertility in several ways: distorted anatomy of the pelvis, adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality.
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
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This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
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How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
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2. Endometriosis is defined as the presence of
endometrial-like tissue outside the uterus,
which induces a chronic, inflammatory
reaction.
3. Which symptoms are typically associated with
endometriosis?
• severe dysmenorrhoea
• deep dyspareunia
• chronic pelvic pain
• ovulation pain
• cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal
bleeding or pain
• infertility
• chronic fatigue
• dyschezia (pain on defaecation).
4. Sign
• Deeply infiltrating nodules are most reliably detected when clinical
examination is performed during menstruation.
• Pelvic tenderness
• Fixed, retroverted uterus
• Tender uterosacral ligaments or
• Enlarged ovaries
6. What is the ‘gold standard’ diagnostic test?
Visual inspection of the pelvis at laparoscopy
• diagnostic laparoscopy is associated with an approximately 3% risk of minor
complications, such as nausea or shoulder tip pain, and
• a risk of major complications, such as bowel perforation, vascular damage,
of between 0.6/1000 and 1.8/1000
• should not be performed during or within 3 months of hormonal treatment,
to avoid under-diagnosis
• Appearance: blackened spot, red implants, vesicles. Peritoneal defects and
endometriomas.
8. Surgically, endometriosis can be staged I–IV (Revised Classification of the American Society of Reproductive Medicine).[42]
but it is important to note staging assesses physical disease only, not the level of pain or infertility.
A patient with Stage I endometriosis may have little disease and severe pain,
while a patient with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these
findings:
Stage I (Minimal)
Findings restricted to only superficial lesions and possibly a few filmy adhesions
Stage II (Mild)
In addition, some deep lesions are present in the cul-de-sac
Stage III (Moderate)
As above, plus presence of endometriomas on the ovary and more adhesions.
Stage IV (Severe)
As above, plus large endometriomas, extensive adhesions.
Endometrioma on the ovary of any significant size (Approx. 2 cm +) must be removed surgically
because hormonal treatment alone will not remove the full endometrioma cyst,
which can progress to acute pain from the rupturing of the cyst and internal bleeding.
9. How reliable is imaging for diagnostic purposes?
• transvaginal ultrasound (TVS) has limited value in diagnosing peritoneal
endometriosis but it is a useful tool both to make and to exclude the
diagnosis of an ovarian
• there is insufficient evidence to indicate that magnetic resonance imaging
(MRI) is a useful test to diagnose or exclude endometriosis compared to
laparoscopy.
11. How reliable is serum CA125 measurement for
diagnostic purposes?
• Serum CA125 levels may be elevated in endometriosis. However,
compared with laparoscopy, measuring serum CA125 levels has no value
as a diagnostic tool.
• The estimated sensitivity was only 28% for a specificity of 90%.
12. Treatment of Endometriosis
Management of pain
• Surgery
• Medical therapy
Treatment of infertility
• Surgery
• Ovulation induction
• Assisted reproductive technology
14. Treatment of Pain
• Medical management
• Oral contraceptives, progesterone, danazol
• GnRH agonist with add-back
• Alternating GnRH agonist and OCs
• Aromatase inhibitors - letrozole
• NSAID
15. CHOICES OF MEDICAL THERAPY
Drug group Example Side effects
1 Progestogens Medroxyprogesterone
Duphaston
Norculot
Mood swing
Nausea
bloatedness
2 Danazol
(synthetic
androgen)
Danocrine Hoarseness
Hirsuitism, acne
3 Oral contraceptives Any OCPs Weight gain,
bloatedness
4 GnRH analogue Zoladex (Goserelin)
Lucrin
Vasomotor
symptoms/
osteoporosis
16. • COCPs act by ovarian suppression. Initially, a trial of continuous or cyclic
COCPs should be administered for 3 months.
• All progestational agents act by decidualization and atrophy of the
endometrium.
• Duphaston - 10mg bd or tds - from day 5 to day 25 cycle Or Continuously for 6
– 9 months
• GnRH analogues produce a hypogonadotrophic-hypogonadic state by
downregulation of the pituitary gland.
• Goserelin and leuprolide acetate are the commonly used agonists.
• Danazol acts by inhibiting the midcycle follicle-stimulating hormone (FSH)
and luteinizing hormone (LH) surges and preventing steroidogenesis in the
corpus luteum. It is the most extensively studied agent for endometriosis.
• The recommended dose is 600-800 mg/d
17. Empirical treatment of pain symptoms
without a definitive diagnosis
• Therapeutic trial of a hormonal drug to reduce menstrual flow is
appropriate.
• It include counselling, adequate analgesia, progestogens or the combined
oral contraceptive. It is unclear whether the combined oral contraceptives
should be taken conventionally, continuously or in a tricycle regimen.
• A gonadotrophin-releasing hormone (GnRH) agonist may be taken but this
class of drug is more expensive and associated with more adverse effects
and concerns about bone density.
18. How effectively do nonsteroidal
anti-inflammatory drugs (NSAIDs)
treat endometriosis-associated
pain?
• There is inconclusive evidence to
show whether NSAIDs
(specifically naproxen) are
effective in managing the pain.
Is there a role for the
levonorgestrel intrauterine
system (LNG-IUS)?
• The LNG-IUS appears to reduce
endometriosis-associated pain.
20. Management of Pain
• Surgical treatment
• Ablation of endometrial implants
• Lysis of adhesions
• Ablation of uterosacral nerves
• Resection of endometriomas
• Combined surgical and medical treatment
21. Surgical care can be broadly classified as
• conservative when reproductive potential is retained
• semiconservative when reproductive ability is eliminated but ovarian
function is retained
• radical when the uterus and ovaries are removed.Age, desire for future
childbearing, and deterioration of quality of life are the main considerations
when deciding on the extent of surgery.
22. How should ovarian endometriomas be managed?
• Laparoscopic cystectomy for ovarian endometriomas is better than
drainage and coagulation.
• The recurrence of endometriomas and symptoms are reduced by excisional
surgery more so than drainage and ablation.
• Is there a role for hormonal treatment after surgery?
• Postoperative hormonal treatment has no beneficial effect on pregnancy
rates after surgery.
• Compared with surgery alone or surgery plus placebo, postoperative
hormonal treatment has no effect on pregnancy rates.
24. Dissection of an Endometrioma
Tube
Ovary
Incision
Removal Result
25. When should surgical treatment be considered?
• Ideal practice is to diagnose and remove endometriosis surgically.
Does surgical treatment relieve pain?
• Ablation of endometriotic lesions reduces endometriosis-
associated pain compared with diagnostic laparoscopy.
Does nerve ablation provide pain relief?
• itself does not reduce endometriosis-associated pain.
• presacral neurectomy,especially in severe dysmenorrhoea, although
the evidence is inconclusive.44
26. What is the role of more radical surgery?
• Endometriosis associated pain can be reduced by removing the entire
lesions in severe and deeply infiltrating disease.
• If a hysterectomy is performed, all visible endometriotic tissue should be
removed at the same time.
• Bilateral salpingo-oophorectomy may result in improved pain relief and a
reduced chance of future surgery.
27. Is there a role for surgical treatment of
endometriomas before IVF?
• Laparoscopic ovarian cystectomy is recommended for endometriomas ≥
4 cm in diameter.
• to confirm the diagnosis histologically; reduce the risk of infection; improve
access to follicles, and possibly improve ovarian response and prevent
endometriosis progression
The woman should be counselled regarding the risks of reduced ovarian
function after surgery and the loss of the ovary.The decision should be
reconsidered if she has had previous ovarian surgery.
28. The role of complementary therapies in relieving
endometriosis-associated pain is unclear.
• Many women with endometriosis report that nutritional and
complementary therapies such as homeopathy, reflexology, traditional
Chinese medicine or herbal treatments, do improve pain symptoms.
• While there is no evidence from randomised controlled trials in
endometriosis to support these treatments, they should not be ruled out if
the woman feels that they could be beneficial to her overall pain
management and/or quality of life, or work in conjunction with more
traditional therapies.
29. Long term management
• Endometriosis is progressive and can result in chronic pain and infertility.
Gynecologic follow-up is advised.
31. Case
• A 37 year-old nulliparous lady, married for the last 7 years, complains of
severe dysmenorrhoea of 10 years. She is also very anxious to conceive.
Examination revealed a tender left iliac fossa with a tender mass which has
restricted mobility. Pelvic examination confirms a retroverted uterus with
mobility and a tender mass in the left iliac fossa.
32. Key points
• Endometriosis is a common disease affecting women of the reproductive
age group (10%). It may begin in late adolescence. Symptom –
dysmenorrhoea and infertility.
• Pelvic endometriosis causes scarring, fibrosis and adhesions.
• There is a role of medical management in mild stage of endometriosis
• The surgical intervention is indicated in moderate to severe endometriosis