Endometriosis is a chronic gynecologic disorder that commonly manifests as chronic pain and infertility. It affects 6 to 10 percent of women of reproductive age, and it is present in approximately 38 percent of women with infertility and in up to 87 percent of women with chronic pelvic pain. It is thought to develop from attachment and implantation of endometrial glands and stroma on the peritoneum as a result of retrograde menstruation. Endometrial lesions result from overproduction of prostaglandins and estrogen, which leads to chronic inflammation.
The mechanism by which infertility occurs in women with early-stage endometriosis is not clear. Oxidative stress and higher concentration of inflammatory cytokines may affect sperm function in several ways, including causing sperm DNA damage. The abnormal peritoneal environment can also cause abnormalities in oocyte cytoskeleton function. In more advanced endometriosis with ovarian cysts and adhesions, the anatomic abnormalities can impair tubal function.
Diagnostic evaluation of women with pelvic pain should include a thorough history and physical examination to rule out other gynecologic causes of pain. Nongynecologic causes (e.g., irritable bowel syndrome, interstitial cystitis, urinary tract disorders) can be ruled out with appropriate testing and referrals, if necessary.
Definitive diagnosis of endometriosis can be made only by histology of lesions that have been removed surgically. Imaging studies cannot be used to diagnose endometriosis, but they can be useful in patients with pelvic or adnexal masses. Ovarian endometriomas typically appear on ultrasonography as cysts that contain low-level homogeneous internal echoes consistent with old blood. Imaging alone seems to be highly predictive in differentiating ovarian endometriomas from other adnexal masses.
Transvaginal ultrasonography is the preferred imaging modality to determine the presence of endometriosis and deeply infiltrating endometriosis of the rectum or recto-vaginal septum. Magnetic resonance imaging should be reserved for patients with equivocal ultrasound results and in whom rectovaginal or bladder endometriosis is suspected.Progestins, danazol, extended-cycle combined oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) agonists can be used for initial treatment of pain in women with suspected endometriosis. However, recurrence rates are high after the medication is discontinued. If initial therapy is unsuccessful, diagnostic laparoscopy can be offered to confirm the diagnosis. Alternatively, empiric treatment with another suppressive medication is an option. Empiric therapy with a three-month course of a GnRH agonist is appropriate if initial treatment with oral contraceptives and NSAIDs is unsuccessful. It is important to explain to the patient that response to empiric therapy does not confirm the diagnosis of endometriosis.
ENDOMETRIOSIS UPDATEFocus on Dienogest Dr Sharda jain dr Jyoti Agarwal Lifecare Centre
ENDOMETRIOSIS UPDATEFocus on Dienogest
AGENDA
Background
What’s New in Endometriosis
Clinical Discussions in Managing Endometriosis
Newer Evidences on Dienogest
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
1. The document discusses emerging treatments for endometriosis, including levonorgestrel-releasing intrauterine devices (LNG-IUD), gonadotropin-releasing hormone antagonists (GnRHan), aromatase inhibitors (AIs), selective estrogen receptor modulators (SERMs), and progesterone antagonists.
2. It finds that LNG-IUD is effective for pain control and reduction in endometriosis lesions. GnRHan provide immediate hormone suppression with fewer side effects than agonists. AIs reduce estrogen levels through multiple pathways and show promise when combined with other drugs, though require further research. SERMs and progesterone antagonists aim to block estrogen and progesterone's
Recent advances in endometriosis were discussed. Endometriosis is a chronic disease where endometrial tissue grows outside the uterus, affecting around 10% of women. Dienogest, a progestin, was shown to be effective in reducing endometriosis-associated pelvic pain in randomized controlled trials. Dienogest 2mg daily for 24 weeks provided pain relief similar to leuprolide acetate but with fewer side effects. Long-term use of dienogest for 65 weeks maintained pain relief with a favorable safety profile. Dienogest was as effective as goserelin in reducing postoperative recurrence of endometriosis at 24 months.
This document provides information on progestins and their use in treating endometriosis. It focuses on dienogest, a new hybrid progestin. It discusses dienogest's pharmacological properties, advantages over other treatments like GnRH agonists, and clinical trial results showing its efficacy and safety. Long-term use of up to 52 weeks is shown to control symptoms with minimal side effects. Dienogest also allows for prompt return of fertility and ovulation after treatment.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGESTLifecare Centre
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGEST
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
ENDOMETRIOSIS UPDATEFocus on Dienogest Dr Sharda jain dr Jyoti Agarwal Lifecare Centre
ENDOMETRIOSIS UPDATEFocus on Dienogest
AGENDA
Background
What’s New in Endometriosis
Clinical Discussions in Managing Endometriosis
Newer Evidences on Dienogest
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
1. The document discusses emerging treatments for endometriosis, including levonorgestrel-releasing intrauterine devices (LNG-IUD), gonadotropin-releasing hormone antagonists (GnRHan), aromatase inhibitors (AIs), selective estrogen receptor modulators (SERMs), and progesterone antagonists.
2. It finds that LNG-IUD is effective for pain control and reduction in endometriosis lesions. GnRHan provide immediate hormone suppression with fewer side effects than agonists. AIs reduce estrogen levels through multiple pathways and show promise when combined with other drugs, though require further research. SERMs and progesterone antagonists aim to block estrogen and progesterone's
Recent advances in endometriosis were discussed. Endometriosis is a chronic disease where endometrial tissue grows outside the uterus, affecting around 10% of women. Dienogest, a progestin, was shown to be effective in reducing endometriosis-associated pelvic pain in randomized controlled trials. Dienogest 2mg daily for 24 weeks provided pain relief similar to leuprolide acetate but with fewer side effects. Long-term use of dienogest for 65 weeks maintained pain relief with a favorable safety profile. Dienogest was as effective as goserelin in reducing postoperative recurrence of endometriosis at 24 months.
This document provides information on progestins and their use in treating endometriosis. It focuses on dienogest, a new hybrid progestin. It discusses dienogest's pharmacological properties, advantages over other treatments like GnRH agonists, and clinical trial results showing its efficacy and safety. Long-term use of up to 52 weeks is shown to control symptoms with minimal side effects. Dienogest also allows for prompt return of fertility and ovulation after treatment.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGESTLifecare Centre
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGEST
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
2018 Popular Endometriosis Treatment Options Introduction !singletons li
Endometriosis Treatment Options can be divided into two types : Endometriosis Surgery Treatment and Home Remedies For Endometriosis like Endometriosis Herbal Treatment and here,the article presents 2018 Popular Endometriosis Alternative Treatment ,check it to get more informations.
Overview of currently available treatment options for AUB Dr. Jyoti Agarwal D...Lifecare Centre
This document summarizes treatment options for abnormal uterine bleeding (AUB). It discusses medical therapies like hormonal treatments, NSAIDs, and hemostatic agents as first-line options. Surgery is reserved for cases where medical therapy fails or is contraindicated. The treatment approach is individualized based on factors like age, symptoms, and any structural abnormalities. A PALM-COEIN framework is presented for guiding management based on identified causes of AUB. LNG-IUS is highlighted as an effective first-line treatment for many causes of AUB.
Endometriosis An Overview Dr. Namitha Kapoor, Dr. Sharda jain , Dr. jyoti Ag...Lifecare Centre
Endometriosis is a debilitating disease where tissue similar to the uterine lining grows outside the uterus, affecting around 10% of women. Common symptoms include painful periods, pain with intercourse, and chronic pelvic pain. While the exact cause is unknown, excess estrogen is thought to stimulate inflammation, invasion, angiogenesis and cell proliferation that leads to lesions, adhesions and pain. Treatment options aim to achieve a reduced estrogenic state and include surgery to remove lesions and adhesions as well as medical options like hormonal therapies, though these have limitations such as side effects and high recurrence rates of pain after surgery. Guidelines recommend considering progestins as a first choice medical treatment for endometriosis.
Best Clinical Practice Guidelines Ever Produced on Management of EndometriosisLifecare Centre
This document provides guidelines for the management of endometriosis. It addresses key questions regarding symptoms, diagnosis, treatment of pain, and prevention. Some main points covered include:
- Common symptoms associated with endometriosis include dysmenorrhea, pelvic pain, and infertility.
- Laparoscopy with histological examination is the gold standard for diagnosis but can have a delay of 4-10 years.
- Hormonal therapies, analgesics, and surgery are effective treatments for painful symptoms. For surgery, laparoscopy is preferred over laparotomy when possible.
- Secondary prevention with hormonal contraceptives after surgery may help reduce recurrence of disease and pain.
This document discusses emerging treatments for endometriosis. It begins by outlining the limitations of current treatments, such as being suppressive rather than curative, interfering with fertility, and having limited effectiveness for certain disease phenotypes. The document then examines the criteria for an ideal endometriosis medication and evaluates several emerging hormonal and non-hormonal treatments. These include gonadotropin-releasing hormone antagonists, selective progesterone receptor modulators, aromatase inhibitors, immunomodulators, and other agents. For many of the treatments, human and animal studies are summarized that demonstrate reductions in pain, lesion size, or other beneficial outcomes for endometriosis.
Update (2021) Oral Contraceptive Pill : Dr. Jyoti Agarwal Dr Sharda Jain Lifecare Centre
Update (2021) Oral Contraceptive Pill : Dr Sharda Jain
7 Billion 2011 & increasing a rate of 150 million per year
INDIA
Today – 1.3 billion 2050 – 1.628 expected
This document provides guidelines for the diagnosis and management of endometriosis. It discusses the symptoms of endometriosis and recommends laparoscopy with biopsy as the gold standard for diagnosis. For treatment of pain, it recommends initially treating empirically with adequate analgesia, hormonal contraceptives, progestagens, or GnRH agonists. It provides details on the use of various hormonal options like combined oral contraceptives, progestins, and aromatase inhibitors to reduce endometriosis-associated pain.
This document discusses endometriosis, including its pathogenesis, medical interventions, and changing treatment paradigms. It presents the case of a 25-year old woman with worsening pelvic pain and notes 80 ongoing clinical trials on the topic. New insights into biomarkers have led to newer medical treatments. While surgery was traditionally prioritized, endometriosis is now viewed primarily as a medical disease, with medical treatment preferred for superficial disease and surgery as back-up. The effectiveness of medical treatments like GnRH agonists and IUDs for pain and improved fertility with GnRH agonists prior to ART are summarized.
Dr. Sharda Jain, Dr. Jyoti Agarwal, and Dr. Jyoti Bhaskar presented an interactive session on the medical management of dysfunctional uterine bleeding (DUB) in 2014. Ormeloxifene, a selective estrogen receptor modulator, was discussed as a non-steroidal treatment option for DUB that has shown efficacy in several pilot studies and randomized controlled trials. Ormeloxifene has advantages of a convenient dosing schedule and few side effects, and has been used to successfully treat over 700 patients with DUB. Feedback was encouraged from participants on experiences treating DUB.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
This document discusses endometriosis, including its presentation, diagnosis, and various treatment options. It provides details on:
- The symptoms of endometriosis including pain, infertility, and how it impacts fecundity.
- Laparoscopy being the gold standard for diagnosis, as it allows visualization and histological confirmation.
- Treatment options including medical management for pain, and surgical excision or ablation for pain or infertility depending on severity and location of lesions.
- Surgical considerations for different types and locations of endometriosis such as endometriomas, deep infiltrating endometriosis, and prevention of post-operative adhesions.
Diagnosis & Management of Endometriosis: pathophysilogy to practiceAzizan Hanny
This document provides information about a module on the diagnosis and management of endometriosis. It discusses the pathophysiology, symptoms, historical background, theories of pathogenesis, and diagnosis and treatment of endometriosis. The module includes an online monograph, PowerPoint slides, and interactive case studies to educate medical professionals on timely diagnosis and effective treatment of endometriosis to improve outcomes for patients.
Endometriosis: A changing paradigm from surgical to medical therapyMahmoud Abdel-Aleem
This document discusses changing the treatment paradigm for endometriosis from primarily surgical to primarily medical therapy. It notes that our understanding of the pathogenesis and presentation of endometriosis is evolving. Medical treatments can now better target the disease's inflammatory nature. While surgery remains important, medical therapy as a first-line or adjunctive approach has advantages like preserving ovarian reserve and addressing disease recurrence or involvement of other organs. Established and investigational medical options are reviewed along with principles of optimizing care and assessing outcomes given challenges evaluating treatments for this condition.
This document summarizes research on central nervous system (CNS) changes associated with endometriosis. It discusses 1) changes in brain function seen with functional MRI and PET scans, 2) alterations in brain structure with decreases in grey matter volume, 3) decreased activity of the hypothalamic-pituitary-adrenal axis, 4) increased psychological distress, and 5) autonomic nervous system changes. These CNS changes may amplify or generate pain independently and help explain disparities between disease extent and pain levels as well as pain that persists after treatment. Future treatments may need to target both peripheral and central pain mechanisms.
This document discusses selective progesterone receptor modulators (SPRM) and their uses in gynecology. It provides background on the initial development of mifepristone as a progesterone receptor antagonist in the 1980s. More recently, ulipristal acetate, a SPRM, has been licensed for emergency contraception and as a preoperative treatment for uterine fibroids. The document outlines the mechanism of action of SPRMs as having mixed agonist and antagonist effects on progesterone receptors. It also summarizes recent clinical trials showing ulipristal acetate to be an effective alternative to gonadotropin-releasing hormone analogues for preoperative treatment of uterine fibroids, with reduced side effect profiles compared to analogues.
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”
1. Endometriosis involves endometrial tissue growing outside the uterus, most commonly on the ovaries, fallopian tubes, and tissue lining the pelvis.
2. It affects 6-10% of women and is a common cause of pelvic pain and infertility. While progression can be slow, it is a chronic condition with no permanent cure.
3. Diagnosis is often delayed due to non-specific symptoms like pelvic pain and difficulty becoming pregnant. Laparoscopy with biopsy of suspicious lesions remains the gold standard for diagnosis but ultrasound and MRI may also help identify locations of endometrial growth.
This document discusses laparoscopic ovarian drilling (LOD) for the treatment of infertility in patients with polycystic ovary syndrome (PCOS). It provides an overview of the debate around LOD and recommends it as a second-line therapy for clomiphene-resistant PCOS patients. The document emphasizes adjusting the number of punctures and thermal dose based on individual ovarian volume to minimize risks like diminished ovarian reserve while maximizing effectiveness. Key recommendations include using the lowest effective energy levels per puncture and limiting treatment to one ovary to avoid potential long-term complications of LOD.
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
This document discusses medical management options for dysfunctional uterine bleeding (DUB). It begins by defining DUB and outlining treatment goals of controlling bleeding, correcting related conditions, preventing recurrence, and improving quality of life. First line treatment is recommended to be a levonorgestrel-releasing intrauterine system. Other options discussed include tranexamic acid, NSAIDs, combined oral contraceptives, and various progestogen therapies. Ormeloxifene is presented as an ideal selective estrogen receptor modulator for DUB due to its tissue-specific effects and safety profile. Studies demonstrate its effectiveness in reducing bleeding and improving outcomes for women with DUB.
GnRH Agonist in Endometriosis- An Old Good FriendSujoy Dasgupta
Invited Lecture delivered by Dr Sujoy Dasgupta in the "Dream City Meet"- the East Zone Conference of Endometriosis Society of India, held on 24 December 2019 at Durgapur
2018 Popular Endometriosis Treatment Options Introduction !singletons li
Endometriosis Treatment Options can be divided into two types : Endometriosis Surgery Treatment and Home Remedies For Endometriosis like Endometriosis Herbal Treatment and here,the article presents 2018 Popular Endometriosis Alternative Treatment ,check it to get more informations.
Overview of currently available treatment options for AUB Dr. Jyoti Agarwal D...Lifecare Centre
This document summarizes treatment options for abnormal uterine bleeding (AUB). It discusses medical therapies like hormonal treatments, NSAIDs, and hemostatic agents as first-line options. Surgery is reserved for cases where medical therapy fails or is contraindicated. The treatment approach is individualized based on factors like age, symptoms, and any structural abnormalities. A PALM-COEIN framework is presented for guiding management based on identified causes of AUB. LNG-IUS is highlighted as an effective first-line treatment for many causes of AUB.
Endometriosis An Overview Dr. Namitha Kapoor, Dr. Sharda jain , Dr. jyoti Ag...Lifecare Centre
Endometriosis is a debilitating disease where tissue similar to the uterine lining grows outside the uterus, affecting around 10% of women. Common symptoms include painful periods, pain with intercourse, and chronic pelvic pain. While the exact cause is unknown, excess estrogen is thought to stimulate inflammation, invasion, angiogenesis and cell proliferation that leads to lesions, adhesions and pain. Treatment options aim to achieve a reduced estrogenic state and include surgery to remove lesions and adhesions as well as medical options like hormonal therapies, though these have limitations such as side effects and high recurrence rates of pain after surgery. Guidelines recommend considering progestins as a first choice medical treatment for endometriosis.
Best Clinical Practice Guidelines Ever Produced on Management of EndometriosisLifecare Centre
This document provides guidelines for the management of endometriosis. It addresses key questions regarding symptoms, diagnosis, treatment of pain, and prevention. Some main points covered include:
- Common symptoms associated with endometriosis include dysmenorrhea, pelvic pain, and infertility.
- Laparoscopy with histological examination is the gold standard for diagnosis but can have a delay of 4-10 years.
- Hormonal therapies, analgesics, and surgery are effective treatments for painful symptoms. For surgery, laparoscopy is preferred over laparotomy when possible.
- Secondary prevention with hormonal contraceptives after surgery may help reduce recurrence of disease and pain.
This document discusses emerging treatments for endometriosis. It begins by outlining the limitations of current treatments, such as being suppressive rather than curative, interfering with fertility, and having limited effectiveness for certain disease phenotypes. The document then examines the criteria for an ideal endometriosis medication and evaluates several emerging hormonal and non-hormonal treatments. These include gonadotropin-releasing hormone antagonists, selective progesterone receptor modulators, aromatase inhibitors, immunomodulators, and other agents. For many of the treatments, human and animal studies are summarized that demonstrate reductions in pain, lesion size, or other beneficial outcomes for endometriosis.
Update (2021) Oral Contraceptive Pill : Dr. Jyoti Agarwal Dr Sharda Jain Lifecare Centre
Update (2021) Oral Contraceptive Pill : Dr Sharda Jain
7 Billion 2011 & increasing a rate of 150 million per year
INDIA
Today – 1.3 billion 2050 – 1.628 expected
This document provides guidelines for the diagnosis and management of endometriosis. It discusses the symptoms of endometriosis and recommends laparoscopy with biopsy as the gold standard for diagnosis. For treatment of pain, it recommends initially treating empirically with adequate analgesia, hormonal contraceptives, progestagens, or GnRH agonists. It provides details on the use of various hormonal options like combined oral contraceptives, progestins, and aromatase inhibitors to reduce endometriosis-associated pain.
This document discusses endometriosis, including its pathogenesis, medical interventions, and changing treatment paradigms. It presents the case of a 25-year old woman with worsening pelvic pain and notes 80 ongoing clinical trials on the topic. New insights into biomarkers have led to newer medical treatments. While surgery was traditionally prioritized, endometriosis is now viewed primarily as a medical disease, with medical treatment preferred for superficial disease and surgery as back-up. The effectiveness of medical treatments like GnRH agonists and IUDs for pain and improved fertility with GnRH agonists prior to ART are summarized.
Dr. Sharda Jain, Dr. Jyoti Agarwal, and Dr. Jyoti Bhaskar presented an interactive session on the medical management of dysfunctional uterine bleeding (DUB) in 2014. Ormeloxifene, a selective estrogen receptor modulator, was discussed as a non-steroidal treatment option for DUB that has shown efficacy in several pilot studies and randomized controlled trials. Ormeloxifene has advantages of a convenient dosing schedule and few side effects, and has been used to successfully treat over 700 patients with DUB. Feedback was encouraged from participants on experiences treating DUB.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
This document discusses endometriosis, including its presentation, diagnosis, and various treatment options. It provides details on:
- The symptoms of endometriosis including pain, infertility, and how it impacts fecundity.
- Laparoscopy being the gold standard for diagnosis, as it allows visualization and histological confirmation.
- Treatment options including medical management for pain, and surgical excision or ablation for pain or infertility depending on severity and location of lesions.
- Surgical considerations for different types and locations of endometriosis such as endometriomas, deep infiltrating endometriosis, and prevention of post-operative adhesions.
Diagnosis & Management of Endometriosis: pathophysilogy to practiceAzizan Hanny
This document provides information about a module on the diagnosis and management of endometriosis. It discusses the pathophysiology, symptoms, historical background, theories of pathogenesis, and diagnosis and treatment of endometriosis. The module includes an online monograph, PowerPoint slides, and interactive case studies to educate medical professionals on timely diagnosis and effective treatment of endometriosis to improve outcomes for patients.
Endometriosis: A changing paradigm from surgical to medical therapyMahmoud Abdel-Aleem
This document discusses changing the treatment paradigm for endometriosis from primarily surgical to primarily medical therapy. It notes that our understanding of the pathogenesis and presentation of endometriosis is evolving. Medical treatments can now better target the disease's inflammatory nature. While surgery remains important, medical therapy as a first-line or adjunctive approach has advantages like preserving ovarian reserve and addressing disease recurrence or involvement of other organs. Established and investigational medical options are reviewed along with principles of optimizing care and assessing outcomes given challenges evaluating treatments for this condition.
This document summarizes research on central nervous system (CNS) changes associated with endometriosis. It discusses 1) changes in brain function seen with functional MRI and PET scans, 2) alterations in brain structure with decreases in grey matter volume, 3) decreased activity of the hypothalamic-pituitary-adrenal axis, 4) increased psychological distress, and 5) autonomic nervous system changes. These CNS changes may amplify or generate pain independently and help explain disparities between disease extent and pain levels as well as pain that persists after treatment. Future treatments may need to target both peripheral and central pain mechanisms.
This document discusses selective progesterone receptor modulators (SPRM) and their uses in gynecology. It provides background on the initial development of mifepristone as a progesterone receptor antagonist in the 1980s. More recently, ulipristal acetate, a SPRM, has been licensed for emergency contraception and as a preoperative treatment for uterine fibroids. The document outlines the mechanism of action of SPRMs as having mixed agonist and antagonist effects on progesterone receptors. It also summarizes recent clinical trials showing ulipristal acetate to be an effective alternative to gonadotropin-releasing hormone analogues for preoperative treatment of uterine fibroids, with reduced side effect profiles compared to analogues.
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”
1. Endometriosis involves endometrial tissue growing outside the uterus, most commonly on the ovaries, fallopian tubes, and tissue lining the pelvis.
2. It affects 6-10% of women and is a common cause of pelvic pain and infertility. While progression can be slow, it is a chronic condition with no permanent cure.
3. Diagnosis is often delayed due to non-specific symptoms like pelvic pain and difficulty becoming pregnant. Laparoscopy with biopsy of suspicious lesions remains the gold standard for diagnosis but ultrasound and MRI may also help identify locations of endometrial growth.
This document discusses laparoscopic ovarian drilling (LOD) for the treatment of infertility in patients with polycystic ovary syndrome (PCOS). It provides an overview of the debate around LOD and recommends it as a second-line therapy for clomiphene-resistant PCOS patients. The document emphasizes adjusting the number of punctures and thermal dose based on individual ovarian volume to minimize risks like diminished ovarian reserve while maximizing effectiveness. Key recommendations include using the lowest effective energy levels per puncture and limiting treatment to one ovary to avoid potential long-term complications of LOD.
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
This document discusses medical management options for dysfunctional uterine bleeding (DUB). It begins by defining DUB and outlining treatment goals of controlling bleeding, correcting related conditions, preventing recurrence, and improving quality of life. First line treatment is recommended to be a levonorgestrel-releasing intrauterine system. Other options discussed include tranexamic acid, NSAIDs, combined oral contraceptives, and various progestogen therapies. Ormeloxifene is presented as an ideal selective estrogen receptor modulator for DUB due to its tissue-specific effects and safety profile. Studies demonstrate its effectiveness in reducing bleeding and improving outcomes for women with DUB.
GnRH Agonist in Endometriosis- An Old Good FriendSujoy Dasgupta
Invited Lecture delivered by Dr Sujoy Dasgupta in the "Dream City Meet"- the East Zone Conference of Endometriosis Society of India, held on 24 December 2019 at Durgapur
Presentation given in 2018 on Endometriosis - management in the infertility setting. When are assisted reproductive technologies used and what are the medications used for dealing with this condition?
The document discusses guidelines for treating premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). It finds that drospirenone-containing combined oral contraceptives (COCs) and selective serotonin reuptake inhibitors (SSRIs) should be considered first-line pharmaceutical treatments for PMS. Cognitive behavioral therapy is also recommended routinely for severe PMS. For severe cases, gonadotropin-releasing hormone (GnRH) analogues may be used, usually to aid diagnosis or for short-term treatment. Surgery is only indicated for select refractory cases after unsuccessful medical management and GnRH analogue testing.
Medical management of dub – new modalities dr. jyoti bhaskar lecture 4Lifecare Centre
This document discusses treatment options for dysfunctional uterine bleeding (DUB). It begins by defining heavy menstrual bleeding and noting the goals of treatment. It recommends a woman-centered approach. The NICE guidelines recommend levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line treatment, followed by tranexamic acid or NSAIDs as second-line options. Third-line includes oral or injected progestogens. It also discusses the use of oral contraceptives, progestational agents like medroxyprogesterone acetate, and the potential role of selective estrogen receptor modulators like ormeloxifene. Surgical and medical management are compared.
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
Management : Endometriosis & Pain Dr Sharda Jain Lifecare Centre
1. The document discusses endometriosis and pain management options. It provides an overview of endometriosis and the mechanisms behind the pain associated with the condition.
2. It then summarizes various medical and surgical treatment options for managing endometriosis pain. Medical options discussed include NSAIDs, combined hormonal contraceptives, progestins, GnRH agonists, and aromatase inhibitors. The mechanisms, effectiveness, and side effects of each are outlined.
3. Surgical treatment approaches like conservative and definitive surgery are also summarized. Conservative surgery aims to relieve pain while preserving fertility, while definitive surgery involves oophorectomy or hysterectomy to induce menopause in women who do not desire future
This document discusses the management of erectile dysfunction. It provides an overview of various treatment considerations including lifestyle modifications, medication changes, psychosexual therapy, hormonal therapy, pharmacologic therapy, and medical devices or surgery. Pharmacologic therapies discussed in detail include phosphodiesterase type 5 inhibitors like sildenafil, tadalafil, and avanafil. Intracavernosal injection therapies using alprostadil, papaverine, and phentolamine are also covered. The document provides guidance on optimizing effects, precautions, side effects and considerations for various erectile dysfunction treatment options.
Evidence based medical management of aub different optionsNeeta Dhabhai
This document discusses various treatment options for abnormal uterine bleeding (AUB). It outlines both non-hormonal and hormonal medical therapies, including NSAIDs, tranexamic acid, combined hormonal contraceptives, the levonorgestrel IUS, and progestins. It also discusses newer options, lifestyle interventions, the use of various treatments for different conditions, and their effectiveness and side effects based on clinical studies and guidelines.
Nulife module 7 controversies and conclusions editedManinder Ahuja
These six modules from 2-7 are on mid life health care of women and were made with intention of training general gynecologist and other speciality into care of mid life women and have Mid Life OPD cards as mainstay of care.
Oral ketamine can be used as an adjuvant analgesic in palliative care patients to help manage refractory pain. Low dose oral ketamine has been shown to reduce opioid consumption and improve pain relief when used together with opioids like morphine. While studies have not found oral ketamine to provide statistically significant pain relief on its own, it appears to have an opioid-sparing effect. Based on the evidence, an initial oral dose of 0.25-0.5 mg/kg of ketamine is recommended when used adjunctively with opioids in palliative care patients. Close monitoring is needed due to potential side effects like hallucinations.
The document discusses progestogens, which include progesterone and synthetic progestins. Progesterone is secreted naturally, while progestins have progesterone-like effects. Both are used for obstetric and gynecologic purposes. Therapeutically, progestogens are used to support early pregnancy, treat menstrual disorders, provide luteal phase support in assisted reproduction, and relieve symptoms of conditions like endometriosis. While generally effective, studies on uses like threatened miscarriage and preterm labor have been limited by small sample sizes. Natural progesterone generally has fewer side effects than progestins. The document examines various progestogen types and routes of administration.
This document discusses the pharmacology of postoperative pain management. It outlines various tools for pain assessment and factors to consider when evaluating a patient in pain. It then covers the principles of multimodal analgesia, including both pharmacological and non-pharmacological modalities. The major drug classes discussed are NSAIDs, opioids, and various adjuvants. Risks and guidelines for use are provided for different analgesic classes.
Contraception, Hormones, Progestogens: Update : Dr. Jyoti agarwal Dr. Sharda ...Lifecare Centre
This document discusses oral contraceptive pills, specifically those containing progestogens like desogestrel. It provides information on the history and development of oral contraceptives, including how progestogen formulations have evolved to reduce androgenic side effects. Clinical trial results are presented showing that contraceptives containing desogestrel have good cycle control and low rates of side effects. Desogestrel is highlighted as having favorable characteristics like high selectivity and specificity for progesterone receptors over other steroid receptors.
Role of GnRH agonist in benign gynaecological disordersAboubakr Elnashar
GnRH agonists can be used to treat several benign gynecological disorders by inducing a hypoestrogenic state. They work by initially stimulating the pituitary gland but then downregulating it, decreasing FSH and LH levels and sex steroid production. This document discusses their use for: 1) endometriosis, 2) uterine fibroids, 3) thinning the endometrium prior to ablation, 4) pituitary downregulation in IVF, and 5) adenomyosis. For fibroids and endometriosis, GnRH agonists reduce symptoms and shrink lesions over 3-6 months to facilitate surgery. "Add-back" hormone therapy can prevent side effects of hypoestrogenism. For breast
Comparitive Study of the Efficacy and Tolerance of Prokinetic Drugs - Metaclo...pharmaindexing
Comparitive Study of the Efficacy and Tolerance of Prokinetic Drugs - Metaclopramide and Cinetapride In the Treatment of Functional Dyspepsia - A Randomised Controlled Trial
Similar to Medical management of endometriosis by dr alka mukherjee apurva mukherjee (20)
Management of anaemia in pregnancy BY DR ALKA MUKHERJEE DR APURVA MUKHERJEE N...alka mukherjee
Prenatal vitamins typically contain iron. Taking a prenatal vitamin that contains iron can help prevent and treat iron deficiency anemia during pregnancy. In some cases, your health care provider might recommend a separate iron supplement. During pregnancy, you need 27 milligrams of iron a day.
Good nutrition also can prevent iron deficiency anemia during pregnancy. Dietary sources of iron include lean red meat, poultry and fish. Other options include iron-fortified breakfast cereals, prune juice, dried beans and peas.
The iron from animal products, such as meat, is most easily absorbed. To enhance the absorption of iron from plant sources and supplements, pair them with a food or drink high in vitamin C — such as orange juice, tomato juice or strawberries. If you take iron supplements with orange juice, avoid the calcium-fortified variety. Although calcium is an essential nutrient during pregnancy, calcium can decrease iron absorption.
How is iron deficiency anemia during pregnancy treated?
If you are taking a prenatal vitamin that contains iron and you are anemic, your health care provider might recommend testing to determine other possible causes. In some cases, you might need to see a doctor who specializes in treating blood disorders (hematologist). If the cause is iron deficiency, additional supplemental iron might be suggested. If you have a history of gastric bypass or small bowel surgery or are unable to tolerate oral iron, you might need intravenous iron administration. Oral iron is recommended as the first line treatment, with repeated checking of Hb at 2 to 3 weeks after starting treatment to assess compliance, correct administration and response to treatmentOnce Hb reaches the normal range, it is recommended that iron replacement should continue for three months and until at least six weeks postpartumIntravenous (IV) iron is recommended for women who could not tolerate or respond to oral iron, and for those with moderately severe to severe anemia (Hb ≤ 90 g/LHb be measured within 24 to 48 hours after delivery in women with blood loss more than 500 mL, those with uncorrected anemia detected during pregnancy or those with symptoms suggestive of anemia postnatallyOral iron is recommended for women with Hb <100 g/L postpartum, who are hemodynamically stable, asymptomatic or mild symptomatic
Anemia signs and symptoms include:
• Fatigue
• Weakness
• Pale or yellowish skin
• Irregular heartbeats
• Shortness of breath
• Dizziness or lightheadedness
• Chest pain
• Cold hands and feet
• Headache
Keep in mind, however, that symptoms of anemia are often similar to general pregnancy symptoms. Regardless of whether or not you have symptoms, you'll have blood tests to screen for anemia during pregnancy. If you're concerned about your level of fatigue or any other symptoms, talk to your health care provider.
Secondary amenorrhoea by dr alka mukherjee dr apurva mukherjeealka mukherjee
The first step in the evaluation of any patient with secondary amenorrhea is a urine pregnancy test. Every contraceptive method has a failure rate, and anyone who is menstruating is potentially fertile, regardless of age. [5][6]
If the pregnancy test is negative, consider the clinical picture: hirsutism, acne, and a long history of infrequent and irregular menses suggest polycystic ovarian syndrome. By the Rotterdam criteria, a patient may be diagnosed with PCOS if she has two of the following: clinical or chemical hyperandrogenism, oligo- or amenorrhea, or polycystic ovaries on ultrasound. So if a patient has evidence of hirsutism and oligo- or amenorrhea, she can be diagnosed with PCOS without further laboratory testing or imaging.
If history and physical exam are not consistent with PCOS, a TSH should be ordered. Both hyper- and hypothyroidism can lead to menstrual dysfunction.
If TSH is normal, check a serum prolactin. Elevated serum prolactin suggests prolactinoma.
Early pregnancy loss by dr alka mukherjee dr apurva mukherjee nagpur ms indiaalka mukherjee
Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including expectant, medical, and surgical management.
Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation 1. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably, and there is no consensus on terminology in the literature.
Pprom by dr alka mukherjee dr apurva mukherjee nagpur indiaalka mukherjee
Preterm premature rupture of the membranes (PPROM) is a pregnancy complication. In this condition, the sac (amniotic membrane) surrounding your baby breaks (ruptures) before week 37 of pregnancy. Once the sac breaks, you have an increased risk for infection. You also have a higher chance of having your baby born early.
In most cases of PPROM, the cause is not known.
These things may increase risk:
• Having a preterm birth in a previous pregnancy
• Having an infection in your reproductive system
• Vaginal bleeding during pregnancy
• Smoking during pregnancy
Symptoms can occur a bit differently in each pregnancy. They can include:
• A sudden gush of fluid from your vagina
• Leaking of fluid from your vagina
• A feeling of wetness in your vagina or underwear
Call your healthcare provider right away if you have these symptoms.
The symptoms of this health problem may be similar to symptoms of other conditions. See your healthcare provider for a diagnosis.
Diagnosis
• pH (acid-base) balance testing. The pH balance of amniotic fluid is different from vaginal fluid and urine. Your healthcare provider will put the fluid on a test strip to check the balance.
• Looking at a sample under a microscope. When amniotic fluid is dry, it has a fern-like pattern.
• ultrasound exam. This is done to check the amount of amniotic fluid around baby.
Public education on breast cancer hindi by dr alka mukherjee nagpur ms i...alka mukherjee
Abnormal lump — Breast cancer can be discovered when a lump or other change in the breast or armpit is found by a woman herself or by her healthcare provider. In addition to a lump, other abnormal changes may include dimpling of the skin, a change in the size or shape of one breast, retraction (pulling in) of the nipple when it previously pointed outward, or a discoloration of the skin of the breast not related to infection or skin conditions such as psoriasis or eczema.Mammogram — A mammogram is a very low-dose X-ray of the breast. The breast tissue is compressed for the X-ray, which decreases the thickness of the tissue and holds the breast in position, so the radiologist can find abnormalities more accurately. Each breast is compressed between two panels and X-rayed from two directions (top-down and side-to-side) to make sure all the tissue is examined. Mammograms are currently the best screening modality to detect breast cancer. Some mammograms capture images digitally, offering better clarity, the ability to adjust the image, and a decreased likelihood that the woman will need to return on a different day for repeat pictures.
Cancer cervix awareness in hindi by dr alka mukherjee nagpur ms indiaalka mukherjee
Cervical cancer occurs when the cells in the cervix grow abnormally or out of control. The cervix is part of the female reproductive system. The exact cause of cervical cancer is unknown. Certain strains of the human papillomavirus (HPV), a sexually transmitted disease, cause the majority of cervical cancer.
A new vaccine is available to prevent infection against the two types of HPV that are responsible for the majority of cervical cancer cases and the two types of HPV that are responsible for the majority of genital wart cases. A pap smear test is a preventive measure that can detect precancerous or cancerous cells. Precancerous cells are 100% curable.
Telehealth medico legal aspects by dr alka mukherjee nagpur ms indiaalka mukherjee
The term telehealth includes a broad range of technologies and services to provide patient care and improve the healthcare delivery system as a whole. Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. According to the World Health Organization, telehealth includes, “Surveillance, health promotion and public health functions.”
Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections.
Evolution and current practices in emergency contraceptives BY DR ALKA MUKHER...alka mukherjee
This document provides information on emergency contraceptives, including their evolution and current practices. It discusses various emergency contraceptive methods such as the Yuzpe regimen, levonorgestrel pills, mifepristone, copper IUDs, and the recently approved ulipristal acetate. It summarizes the mechanisms of action, effectiveness, appropriate timing, side effects, limitations and safety considerations of the different emergency contraceptive options. The document concludes that emergency contraception can effectively reduce unintended pregnancies and abortions if provided correctly and in a timely manner after unprotected intercourse.
Screening for gestational diabetes an update by dr alka mukherjee nagpur ms i...alka mukherjee
Gestational Diabetes Mellitus (GDM) is defined as any glucose intolerance with the onset or first recognition during pregnancy. This definition helps for diagnosis of unrecognized pre-existing Diabetes also. Hyperglycemia in pregnancy is associated with adverse maternal and prenatal outcome. It is important to screen, diagnose and treat Hyperglycemia in pregnancy to prevent an adverse outcome. There is no international consensus regarding timing of screening method and the optimal cut-off points for diagnosis and intervention of GDM. DIPSI recommends non-fasting Oral Glucose Tolerance Test (OGTT) with 75g of glucose with a cut-off of ≥ 140 mg/dl after 2-hours, whereas WHO (1999) recommends a fasting OGTT after 75g glucose with a cut-off plasma glucose of ≥ 140 mg/dl after 2-hour. The recommendations by ADA/IADPSG for screening women at risk of diabetes is as follows, for first and subsequent trimester at 24-28 weeks a criteria of diagnosis of GDM is made by 75 g OGTT and fasting 5.1mmol/l, 1 hour 10.0mmol/l, 2 hour 8.5mmol/l by universal glucose tolerance testing. Critics of these criteria state that it causes over diagnosis of GDM and unnecessary interventions, the controversy however continues. The ACOG still prefer a 2 step procedure, GCT with 50g glucose non-fasting if value > 7.8mmol/l followed by 3-hour OGTT for confirmation of diagnosis. In conclusion based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study as mild degree of dysglycemia are associated with adverse outcome and high prevalence of Type II DM to have international consensus It recommends IADPSG criteria, though controversy exists. The IADPSG criteria is the only outcome based criteria, it has the ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal complications associated with GDM. This one step method has an advantage of simplicity in execution, more patient friendly, accurate in diagnosis and close to international consensus. Keeping in the mind the diversity and variability of Indian population, judging international criteria may not be conclusive, thus further comparative studies are required on different diagnostic criteria in relation to adverse pregnancy outcomes
Hague convention for inter country adoption by dr alka mukherjee nagpur ms indiaalka mukherjee
The Hague Convention on the Protection of Children and Co-operation in Respect of Intercountry Adoption (Convention) is an international agreement to safeguard intercountry adoptions. Concluded on May 29, 1993 in The Hague, the Netherlands, the Convention establishes international standards of practices for intercountry adoptions. The United States signed the Convention in 1994, and the Convention entered into force for the United States on April 1, 2008The Convention applies to all adoptions by U.S. citizens habitually resident in the United States of children habitually resident in any country outside of the United States that is a party to the Convention (Convention countries). Adopting a child from a Convention country is similar in many ways to adopting a child from a country not party to the Convention. However, there are some key differences. In particular, those seeking to adopt may receive greater protections if they adopt from a Convention country.
The Convention requires that countries who are party to it establish a Central Authority to be the authoritative source of information and point of contact in that country. The Department of State is the U.S. Central Authorityfor the Convention.
The Convention aims to prevent the abduction, sale of, or trafficking in children, and it works to ensure that intercountry adoptions are in the best interests of children.
The Convention recognizes intercountry adoption as a means of offering the advantage of a permanent home to a child when a suitable family has not been found in the child's country of origin. It enables intercountry adoption to take place when, among other steps:
1. The child has been deemed eligible for adoption by the child's country of origin; and
2. Due consideration has been given to finding an adoption placement for the child in its country of origin.
The role of judiciary & the legal procedure in an adoption case by dr alka mu...alka mukherjee
Central Adoption Resource Authority (CARA) is the nodal agency to monitor and regulate in-country and intra-country adoption and is a part of Ministry of Women and child care.
Following are the certain essential conditions in order to be eligible to adopt a child:
• The procedure for adoption is different in case of Indian citizen, NRI or a foreign citizen and a child can be adopted by any of the three.
• Irrespective of their gender or marital status, any person is eligible to adopt.
• Provided that a couple is adopting a child, they should have completed two years of stable marriage and both should agree for the adoption.
• 25 years should be the minimum age difference between the child and the adoptive parents.
WHEN CAN A CHILD BE ELIGIBLE TO BE ADOPTED?
• Any orphan, surrendered or abandoned child is legally declared free for adoption by the child welfare committee as per the guidelines of the Central Government of India.
• A child without a legal parent or a guardian or the parents are not capable of taking care of the child anymore is said to be an orphan.
• When a child is deserted or unaccompanied by parents or a guardian and the child welfare committee has declared the child to be abandoned, a child is considered to be abandoned.
• Renounce on account of physical, social and emotional factors that are beyond the control of parents or the guardian is called a surrendered child as declared by the child welfare committee.
• In case of adoption, a child requires to be “legally free”. A child is considered to be legally free if even after trying their level best the police fails to find the true parent or guardian of the child.
WHAT ARE THE NORMAL CONDITIONS TO BE FULFILLED BY PARENTS?
• The adoptive parents need to be mentally, physically and emotionally stable.
• The adoptive parents should be financially stable.
• The adoptive parents should not be suffering from any life- threatening diseases.
• Apart from cases of special needs children, couples with three or more kids are not allowed for adoption.
• A single female is allowed to adopt a child of any gender but a single male is not allowed to adopt a girl child.
• The maximum age limit of a single parents should be 55 years.
Laws , rules & regulations governing adoptions in india by dr alka mukherjee ...alka mukherjee
ADOPTION IN INDIA
The custom and practice of adoption in India dates back to the ancient times. Although the act of adoption remains the same, the objective with which this act is carried out has differed. It usually ranged from the humanitarian motive of caring and bringing up a neglected or destitute child, to a natural desire for a kid as an object of affection, a caretaker in old age, and an heir after death.[iii]
But since adoption comes under the ambit of personal laws, there has not been a scope in the Indian scenario to incorporate a uniform law among the different communities which consist of this melting pot. Hence, this law is governed by various personal laws of different religions.
Adoption is not permitted in the personal laws of Muslims, Christians, Parsis and Jews in India. Hence they usually opt for guardianship of a child through the Guardians and Wards Act, 1890.
Indian citizens who are Hindus, Jains, Sikhs, or Buddhists are allowed to formally adopt a child. The adoption is under the Hindu Adoption and Maintenance Act of 1956 that was enacted in India as a part of the Hindu Code Bills. It brought about a few reforms that liberalized the institution of adoption.
Tuberculosis in prenancy by dr alka mukherjee dr apurva mukherjee nagpur ms i...alka mukherjee
Prevention of Tuberculosis
The BCG vaccine has been incorporated into the National immunization policy of many countries, especially the high burden countries, thereby conferring active immunity from childhood. Nonimmune women travelling to tuberculosis endemic countries should also be vaccinated. It must, however, be noted that the vaccine is contraindicated in pregnancy [72].
The prevention, however, goes beyond this as it is essentially a disease of poverty. Improved living condition is, therefore, encouraged with good ventilation, while overcrowding should be avoided. Improvement in nutritional status is another important aspect of the prevention.
Pregnant women living with HIV are at higher risk for TB, which can adversely influence maternal and perinatal outcomes [73]. As much as 1.1 million people were diagnosed with the co-infection in 2009 alone [2]. Primary prevention of HIV/AIDS is, therefore, another major step in the prevention of tuberculosis in pregnancy. Screening of all pregnant women living with HIV for active tuberculosis is recommended even in the absence of overt clinical signs of the disease.
Isoniazid preventive therapy (IPT) is another innovation of the World Health Organisation that is aimed at reducing the infection in HIV positive pregnant women based on evidence and experience and it has been concluded that pregnancy should not be a contraindication to receiving IPT. However, patient's individualisation and rational clinical judgement is required for decisions such as the best time to provide IPT to pregnant women
Torch infections during pregnancy by dr alka mukherjee nagpur ms indiaalka mukherjee
TORCH Syndrome refers to infection of a developing fetus or newborn by any of a group of infectious agents. "TORCH" is an acronym meaning (T)oxoplasmosis, (O)ther Agents, (R)ubella (also known as German Measles), (C)ytomegalovirus, and (H)erpes Simplex. Infection with any of these agents (i.e., Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex viruses) may cause a constellation of similar symptoms in affected newborns. These may include fever; difficulties feeding; small areas of bleeding under the skin, causing the appearance of small reddish or purplish spots; enlargement of the liver and spleen (hepatosplenomegaly); yellowish discoloration of the skin, whites of the eyes, and mucous membranes (jaundice); hearing impairment; abnormalities of the eyes; and/or other symptoms and findings. Each infectious agent may also result in additional abnormalities that may be variable, depending upon a number of factors (e.g., stage of fetal development
How to develope your personality by dr alka mukherjee nagpur ms indiaalka mukherjee
Personality is what makes a person a unique person, and it is recognizable soon after birth. A child's personality has several components: temperament, environment, and character. Temperament is the set of genetically determined traits that determine the child's approach to the world and how the child learns about the world. There are no genes that specify personality traits, but some genes do control the development of the nervous system, which in turn controls behavior.
A second component of personality comes from adaptive patterns related to a child's specific environment. Most psychologists agree that these two factors—temperament and environment—influence the development of a person's personality the most. Temperament, with its dependence on genetic factors, is sometimes referred to as "nature," while the environmental factors are called "nurture."
While there is still controversy as to which factor ranks higher in affecting personality development, all experts agree that high-quality parenting plays a critical role in the development of a child's personality. When parents understand how their child responds to certain situations, they can anticipate issues that might be problematic for their child. They can prepare the child for the situation or in some cases they may avoid a potentially difficult situation altogether. Parents who know how to adapt their parenting approach to the particular temperament of their child can best provide guidance and ensure the successful development of their child's personality.
Finally, the third component of personality is character—the set of emotional, cognitive, and behavioral patterns learned from experience that determines how a person thinks, feels, and behaves. A person's character continues to evolve throughout life, although much depends on inborn traits and early experiences. Character is also dependent on a person's moral development .
Personality by dr alka mukherjee nagpur ms indiaalka mukherjee
The word personality itself stems from the Latin word persona, which refers to a theatrical mask worn by performers in order to either project different roles or disguise their identities.
At its most basic, personality is the characteristic patterns of thoughts, feelings, and behaviors that make a person unique. It is believed that personality arises from within the individual and remains fairly consistent throughout life.
While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person's behavior.
Explanations for personality can focus on a variety of influences, ranging from genetic explanations for personality traits to the role of the environment and experience in shaping an individual's personality.
Qualitative blood loss in obstetric hemorrhage by dr alka mukherjee indiaalka mukherjee
• Quantitative methods of measuring obstetric blood loss have been shown to be more accurate than visual estimation in determining obstetric blood loss.
• Studies that have compared visual estimation to quantitative measurement have found that visual estimation is more likely to underestimate the actual blood loss when volumes are high and overestimate when volumes are low.
• Although quantitative measurement is more accurate than visual estimation for identifying obstetric blood loss, the effectiveness of quantitative blood loss measurement on clinical outcomes has not been demonstrated.
• Implementation of quantitative assessment of blood loss includes the following two items: 1) use of direct measurement of obstetric blood loss (quantitative blood loss) and 2) protocols for collecting and reporting a cumulative record of blood loss postdelivery.
Dysmenorrhea and related disorders by dr alka mukherjee dr apurva mukherjee n...alka mukherjee
Dysmenorrhea is a common symptom secondary to various gynecological disorders, but it is also represented in most women as a primary form of disease. Pain associated with dysmenorrhea is caused by hypersecretion of prostaglandins and an increased uterine contractility. The primary dysmenorrhea is quite frequent in young women and remains with a good prognosis, even though it is associated with low quality of life. The secondary forms of dysmenorrhea are associated with endometriosis and adenomyosis and may represent the key symptom. The diagnosis is suspected on the basis of the clinical history and the physical examination and can be confirmed by ultrasound, which is very useful to exclude some secondary causes of dysmenorrhea, such as endometriosis and adenomyosis. The treatment options include non-steroidal anti-inflammatory drugs alone or combined with oral contraceptives or progestins.
Dyspareunia & vulvodynia by dr alka mukherjee dr apurva mukherjee nagpur m.s....alka mukherjee
This document discusses dyspareunia (recurring pain during sexual intercourse) and vulvodynia (chronic genital pain). It describes the causes, symptoms, diagnosis, and treatment options. Dyspareunia and vulvodynia can have physical and psychological causes, and treatment may involve medications, physical therapy, cognitive behavioral therapy, and sometimes surgery. A multidisciplinary approach is often needed to properly diagnose and address the underlying causes of genital pain.
Chronic pelvic pain by dr alka mukherjee dr apurva mukherjee nagpur m.s. indiaalka mukherjee
Chronic pelvic pain in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than six months. Often no specific etiology can be identified, and it can be conceptualized as a chronic regional pain syndrome or functional somatic pain syndrome. It is typically associated with other functional somatic pain syndromes (e.g., irritable bowel syndrome, nonspecific chronic fatigue syndrome) and mental health disorders (e.g., posttraumatic stress disorder, depression). Diagnosis is based on findings from the history and physical examination. Pelvic ultrasonography is indicated to rule out anatomic abnormalities. Referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. Curative treatment is elusive, and evidence-based therapies are limited. Patient engagement in a biopsychosocial approach is recommended, with treatment of any identifiable disease process such as endometriosis, interstitial cystitis/painful bladder syndrome, and comorbid depression. Potentially beneficial medications include depot medroxyprogesterone, gabapentin, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists with add-back hormone therapy. Pelvic floor physical therapy may be helpful. Behavioral therapy is an integral part of treatment. In select cases, neuromodulation of sacral nerves may be appropriate. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. Chronic pelvic pain should be managed with a collaborative, patient-centered approach.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
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Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Travel Clinic Cardiff: Health Advice for International Travelers
Medical management of endometriosis by dr alka mukherjee apurva mukherjee
1. MEDICAL MANAGEMENT OF ENDOMETRIOSIS
DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
DR APURVA MUKHERJEE MBBS
1
2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
Director of Mukherjee Multispecialty Hospital
Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
Hon.Secretary AMWN (2018-2021)
Hon.Secretary ISOPARB (2019-2021)
Organizing secretary AMWICON – 2019
Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPRB, HUMAN RIGHTS
Founder Member of South Rapid Action Group,
Nagpur.
On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
Winner of NOGS GOLD MEDAL – 2017-18
Winner of BEST COUPLE AWARD in Social
Work - 2014
VIDARBHA RATNA PURASKAR - 2019
Past Position
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Vice President IMA Nagpur (2017-2018)
Organizing joint secretary ENDO-GYN 2019
2DR ALKA MUKHERJEE
3. Introduction
• Endometriosis - Enigmatic disease - chronic, progressive,
recurrent, debilitating immune mediated disease,
• Definition- The presence of endometrial glands and stroma,
outside the uterine cavity which induces chronic
inflammatory reaction.
• General incidence - around 10 %
• Among the infertile women - 25 – 48 %
• 176 million women or even more in the world suffer from
endometriosis.
• The main symptoms are dysmenorrhoea, dyspareunia,
dysuria, dyschezia, abnormal uterine bleeding and difficulty
in conception.
3DR ALKA MUKHERJEE
8. • The dependence of endometriosis on the woman's cyclic
production of menstrual cycle hormones provides the basis for
medical therapy.
• Medications currently recommended include gonadotropin-
releasing hormone (GnRH) agonists, progestins, oral contraceptive
pills, and androgens.
• Combined low dose hormonal contraceptives - Oral Pills, Use of
vaginal contraceptive ring or a transdermal [oestrogen/progestin]
patch, Continuous use of COC
• Each of these interrupts the normal cyclic production of
reproductive hormones. There are some data supporting the use of
aromatase inhibitors for refractory or recurrent endometriosis.
Medical management of endometriosis
8DR ALKA MUKHERJEE
9. Medical management of endometriosis
a) Empirical treatment, in suspected cases of endometriosis,
to be started, based on the symptoms, after counseling the
women thoroughly.
b) GDG recommends medical therapy for patients of
endometriosis for
1.Prevention of recurrence following surgery and for long
term follow up
2.If recurrence occurs
3.In patients who refuse surgery (Evidence level GPP)
9DR ALKA MUKHERJEE
10. Clinicians should counsel women with
symptoms presumed to be due to
endometriosis [CPP, dysmenorrhoea and
dyspareunia] thoroughly.
Empirical medical management includes
NSAID’s, OCP’s and GnRH agonists. (Evidence
level GPP)
10DR ALKA MUKHERJEE
11. 1. NSAIDs
1. NSAID’s or other analgesics to reduce endometriosis
associated pain should be considered.(Evidence level
GPP)
2. Mefenemic acid is the commonly used NSAIDs
(Evidence level GPP)
11DR ALKA MUKHERJEE
12. Managing endometriosis with hormone
therapy
• Hormone therapies may be used as a treatment for many
stages of endometriosis, or as a combined therapy,
either before or after surgery, for minimal to severe
endometriosis.
• Hormone therapies aim to reduce pain and the severity
of the endometriosis by:
• suppressing the growth of endometrial cells
• stopping any bleeding, including the period.
12DR ALKA MUKHERJEE
13. 2.COC
b) Use of combined low dose hormonal contraceptives
reduces EAPP. [Evidence level-B]
1) Oral Pills [Evidence Level – B]
2) Use of vaginal contraceptive ring or a transdermal
[oestrogen/progestin] patch for EAPP has been
recommended {Evidence level-C]
3) Continuous use of COC may be considered for EAPP.
[Evidence level-C]
13DR ALKA MUKHERJEE
14. • Reduce or eradicate endometrial implants by suppressing
ovulation and the production of oestrogen and
progesterone by the ovaries.
• The low levels of oestrogen in the body - the endometrial
implants are no longer stimulated to grow, and they
break down each month so they gradually shrink or 'dry
up'.
• Temporary chemical 'menopause'.
1)GnRH agonist is effective therapy for EAPP
2)Commonly used GnRh agonist - Leuprolide & Goserelin
[Evidence Level A]
3.GnRh agonist
14DR ALKA MUKHERJEE
15. 3.GnRh agonist
3) Hormonal add-back therapy should be recommended
when GnRH agonist is used for long-term to prevent
bone loss and hypo-estrogenic symptoms [Evidence
level-A]
4) Addition of add-back therapy does not reduce the effect
of treatment for pain relief [Evidence level-A]
5) GnRh agonists in young girls less than 16 years - not
recommended due to adverse effects on BMD [
Evidence level GPP]
6) Vitamin D and Calcium supplementation -
recommended when patients are on GnRH agonist
(Evidence level GPP]
15DR ALKA MUKHERJEE
16. 4. Use of progesterone
Suppress the growth of the endometrial tissue - shrink
gradually and disappear. Provide pain relief for up to 80%
MPA oral or depot, norethisterone acetate, dienogest or
danazol are indicated to reduce EAPP [Evidence level-A]
a. DMPA 150 mg or DMPA SC 104mg - every 3 months. -
Equally effective as GnRH agonists [Evidence level-A]
b. Dienogest at the dose of 2mg/day is as effective as GnRH
agonist but with much less side effects [Evidence level-A]
c. Subdermal implants [Etonogestrol] of depot
Progesterone can be used if available (Evidence level
GPP)
16DR ALKA MUKHERJEE
17. d. Anti-Progestins like Gestrinone are not
commonly used (Evidence level GPP)
e. Levonorgesterol-releasing Intra-uterine system
reduces EAPP as second line [Evidence level-A-B].
It also helps in regressing associated adenomyosis
(Evidence level B)
17DR ALKA MUKHERJEE
18. 5. Danazol
• a). Oral danazol is effective in treatment of
EAPP but serious androgenic side effects
limits its use (Evidence level GPP)
•b). Vaginal Danazol / IUCD loaded with
danazol may be an option and it is
recommended for DIE but it is currently not
available in India (Evidence level GPP)
18DR ALKA MUKHERJEE
19. 6. Aromatase inhibitor
a). Anastrazole [1mg] and Letrozole [2.5mg] can
be given daily for 12 weeks with Progesterone
add-back therapy [Evidence Level B]
7. Anti-Angigenic Therapy
Cabergolin; [0.5 mg weekly twice for 3 months]
reduced EAPP in early lesions and reduces the size
of endometrioma, with comparable effect to LHRH
agonist
19DR ALKA MUKHERJEE
20. 8.Lifestyle Modification
a. Dietary modifications and exercise have
some influence on the severity of symptoms
[Evidence level GPP]
b.Psychotherapy may be beneficial in EAPP
[Evidence level GPP]
20DR ALKA MUKHERJEE
21. HOW IT HELPS WHAT YOU CAN DO
Physical activity and exercise Some gentle activity to keep
your body moving can help to
ease pain
About 20-30 minutes of physical
exercise on most days of the
week is recommended, unless
you have not exercised recently.
If that is the case, you should
begin with smaller amounts and
gradually build up as your fitness
improves
Sleep Having enough quality sleep
every night will help your
immune system function at its
best
•Reduce caffeine and alcohol
intake late at night
•Avoid heavy meals late at night
•Maintain regular timing for
going to bed and waking
Stress management and
relaxation
Finding ways to manage the
stress that endometriosis can
create is important for your
wellbeing
•Try gentle yoga techniques
•Try relaxation skills such as
mindfulness therapy
•Organise your day so you always
have some time out for yourself
•Seek help from a psychologist or
counsellor
Managing endometriosis with a healthy lifestyle
21DR ALKA MUKHERJEE
22. c. There is some evidence to show that Yoga and
meditation help in alleviation of symptoms associated
with EAPP [Evidence level GPP]
d. Alternate therapies like acupuncture and Chinese
herbal medicine reduces EAPP and left to the choice of
the patient [Evidence Level-B]
• f.High frequency TENS may be effective in treatment of
EAPP[Evidence levelGPP]
• e. Multidisciplinary approach is strongly recommended
in EAPP [Evidencelevel GPP ]
22DR ALKA MUKHERJEE
23. Endometriosis & natural therapies
• Alternative treatments, such as transcutaneous
electrical nerve stimulation (TENS), dietary
change, acupuncture and Traditional Chinese
Medicine (TCM), have not shown strong
evidence for management of endometriosis
pain. Scientific studies have not clearly
established either potential benefits and/or
harms. This is an emerging area, so evidence
may change over time.
23DR ALKA MUKHERJEE
24. • Endotone is an efficacious herbal formulation for the management
of endometriosis.
• Endotone effectively delays and stops the proliferation of
endometrial cells. It reduces pain associated with dysmenorrhea and
dyspareunia. It also restores the fertility, reduces the emotional
distress and improves quality of life.
• Musta (Cyperus rotundus) – Controls the proliferation of
endometrial cells, reduces pain
Haridra (Curcuma longa) – Controls proliferation of endometrial
cells, reduces inflammation
Lodhra (Symplocos racemosa) – Improves the hormonal balance
Ashwagandha (Withania somnifera) – Reduces emotional distress,
improves quality of life
Twak (Cinnamomum cassia) – Preserves fertility
Shunthi (Zingiber officinale) – Reduces dysmenorrhea, pain and
inflammation
24DR ALKA MUKHERJEE
28. Adolescent Endometriosis
• Adolescent girls (13 to 19 years) constitute around 3 to 5%
• Girls suffering from chronic pelvic pain - 70 – 80 % are
reported to have endometriosis.
• The presenting features differ from adult population. Most
of them present with severe dysmenorrhoea and school
absenteeism.
• Difficulties in diagnosis as most of them present with
atypical symptoms and are treated empirically.
• The diagnosis is often delayed in the adolescent girls for a
period of more than 6-8 years if high index of suspicion is not
there.
28DR ALKA MUKHERJEE
29. 1. Suspect endometriosis in adolescents when they have severe
dysmenorrhoea, interfering with daily activities and school
absenteeism not responding to NSAIDS and OCPs when taken for
pain relief.
2 Early onset progressive dysmenorrhoea in adolescents should
be investigated for the possibility of Mullerian anomaly with
outflow tract obstruction
3 Diagnosis in adolescents are through history, physical
examination, risk factors and family history combined with imaging
technologies and biomarkers
4.USG and MRI may be done. This may confirm diagnosis only in
advanced lesions. Early lesions may not be picked out
5.When the adolescents do not respond to NSAIDS and OCPs,
diagnostic laparoscopy has to be done to confirm the diagnosis as
well as to treat.
29DR ALKA MUKHERJEE
30. 6.Positive histology confirms the diagnosis, even though
negative histology does not exclude it.
7 Expectant management for adolescent endometriosis
when it is diagnosed incidentally, is debatable
8. Continuous use of OCPs for adolescents - safe and
effective for EAPP and can be used as first line of
treatment
9 . Progestins are also used for endometriosis
associated pelvic pain (EAPP) and have comparable
results with that of GnRH analogues and Danazol.
Newer progestins like dienogest may help to relieve
pain in adolescent girls and can be used for a longer
period.
30DR ALKA MUKHERJEE
31. 9. GnRh agonists are used only for girls beyond 16 years
10 .When DMPA and GnRh are used, BMD reduction has to
be monitored
11 .LNG IUS can be used in sexually active adolescents as
second line of management
12 .Laparoscopy for endometriomas has to be balanced
carefully, to avoid the loss of ovarian reserve Vs pain relief.
13. First surgery should be done by an experienced surgeon
specialized in endometriosis, as adolescent endometriosis has
atypical findings
14. Long term follow up is a must to prevent recurrence
15. Continuous OCPs can reduce the recurrence.
31DR ALKA MUKHERJEE
32. • Likely to recur after medical or surgical therapies
because the basic pathophysiology cannot be corrected.
a.Long-term post-operative OCP’s or progestins to
reduce the risk of recurrence
b. Post -operative use of GnRh agonist for 6 cycles
rather than 3 cycles prevent the recurrence of
endometriosis
c.Oral progestins (MPA, Dienogest, Danazol) are
effective in reducing pain and preventing the
growth of lesion after surgery Dienogest has added
advantage of being anti-inflammatory, anti-
angiogenic and anti-proliferative with less side
effects
Recurrent endometriosis
32DR ALKA MUKHERJEE
33. First line of management of scar endometriosis –
a} wide excision of the mass.
b}Smaller lesions may respond to medical management
with drugs like progestins, OCP’s danazol, GnRh agonists
and dienogest
{They can only reduce the symptoms but not the size of
the lesion.}
33DR ALKA MUKHERJEE
34. ADENOMYOSIS
1.Adenomyosis is defined as a disorder characterized by the
presence of heterotopic endometrial glands and stroma in the
myometrium with hyperplasia of the adjacent smooth muscle
[Evidence level GPP]
2.Adenomyosis is considered relatively common but its exact
incidence has not been accurately determined and ranges from
5 % to 70 % in symptomatic women (Evidence level D]
3.There is increased incidence of adenomyosis in multiparous
women, women getting married at later age, and in women
who had spontaneous abortions undergoing multiple D&Cs.
Generally seen in 3rd
and 4th
decade and rarely seen in
adolescent girls. [Evidence level C]
4.The exact etiology and pathophysiology of uterine
adenomyosis is still unknown. [Evidence level GPP].
34DR ALKA MUKHERJEE
35. • Diagnosis of adenomyosis - TVS, 3D, color Doppler and MRI [
Evidence level C]. MRI is more reliable than TVS and is essential
to plan for uterine sparing surgeries [Evidence level A].
6.Women with adenomyosis present with heavy uterine
bleeding and severe dysmenorrhoea.[ Evidence level
C].
7.Difficulty in conception - unclear how it causes
infertility
Management - Medical or surgical
Surgical management may be conservative or radical
Medical management includes COC’s, GnRh agonists,
Progestins (MPA, Dienogest, Danazol, LNG-IUS), SPRM’s
and SERM
2.Medical management avoids surgery but not very effective in
relieving pain [Evidence level B].
35DR ALKA MUKHERJEE
36. NSAID’s - no effect on the disease and its progression - can be
given for pain relief who want to conceive[Evidence level GPP]
• GnRh provides symptomatic relief, reduces uterine volume and
allows spontaneous conception after cessation of therapy
[Evidence level C]
1.Pre-operative GnRh may reduce the size, vascularity and blood
loss during surgery.
2.This facilitates laparoscopy rather than laparotomy.
3.Sometimes during surgery there may be difficulty in delineating
the marginsand complete excision may be difficult.[Evidence
level C]
Dienogest may be useful in long- term treatment of symptomatic
adenomyosis [Evidence level B].
Oral MPA or injectable DMPA 150mg once in 3 months may be
cost effective in treatment of adenomyosis. [Evidence level A]
36DR ALKA MUKHERJEE
37. LNG-IUS
1. Reduces uterine volume and relieves symptoms within a period
of 3 – 6 months [Evidence level C].
2. Improves quality of life when compare to hysterectomy
3. Relieves chronic pelvic pain associated with adenomyosis
Locally delivered Danazol may be used as an alternate treatment
for symptomatic adenomyosis.
Danazol loaded IUCD’s, rings and intra-cervical injections are
the newer methods of delivering Danazol locally
Continuous combined oral contraceptive pills show overall safety,
good efficacy and appreciable tolerability at low cost [Evidence
level B ].
SERMs and SPRMs have a limited role in clinical practice.[
Evidence level B]
37DR ALKA MUKHERJEE
38. Aromatse inhibitors may be as effective as GnRh agonists
in improving the symptoms and reducing the volume of
adenomyosis [Evidence level B]
Uterine artery embolization may improve the
symptoms of Adenomyosis but recurrence may be
high [Evidence level A].
HIFU and Magnetic Resonance guided ultrasound
are effective ablative technique for symptomatic
adenomyosis
38DR ALKA MUKHERJEE
39. • Medical management in the form of ovulation
suppression is ineffective in improving the pregnancy
rates
• In stage I and II endometriosis, treatment with super
ovulation and IUI improve fertility compared to
expectant management. Clinicians should take into
consideration, age, duration of infertility, ovarian
reserve and male factor
• COS using GnRh agonists or antagonists is effective
in IVF patients with mild to moderate endometriosis
and in those with endometrioma who did not undergo
surgery.
• Ultra-long protocol of GnRh agonists for a period of 3
– 6 months before ART improves the clinical
pregnancy rates
Endometriosis and Infertility
39DR ALKA MUKHERJEE
40. Specific entity, Endometriotic lesions extending more than 5 mm
underneath the peritoneum
Suspect extra-genital endometriosis, when bleeding from
unusual sites e.g: epistaxis, cyclical hemopneumothorax,
haematochezia, haematuria, umbilical bleeding, and previous
scars are seen.
PHYSICAL WXAMINATION:
• P/V - all women suspected of endometriosis
• P/R - adolescents and or women without previous sexual
intercourse
a.Physical examination has poor sensitivity, specificity, and
predictive value
b.Rule out non endometriotic causes in patients complaining of
pelvic pain after thoroughly going through the findings of
combination of history, physical examination, and imaging
studies.
Deep infiltrating endometriosis
40DR ALKA MUKHERJEE
41. Examination, or visible vaginal nodules in the posterior
vaginal fornix -best seen during menstruation.
Suspect presence of ovarian endometrioma in women if
adnexal masses are detected during clinical examination.
Absence of clinical evidence during examination does not
rule out the disease.
Apart from research settings, biomarkers are not
recommended for routine clinical use.
CA-125 may be of value – 1. to rule out ovarian malignancies
and presence of extensive peritoneal lesions.
2. In some cases it may be of
some value for treatment follow-up
41DR ALKA MUKHERJEE