ENDOMETRIOSIS

WHAT IS THE GENERAL PRACTICE APPROACH?

FIRST A FEW QUESTIONS!

IS TREATMENT ALWAYS REQUIRED? WHO NEEDS TREATMENT? DOES ANY TREATMENT REALLY WORK? DOES TREATMENT IN YOUNG WOMEN PREVENT INFERTILITY AND PROGRESSION?

I DONT HAVE THE ANSWERS

ENDOMETRIOSIS PROGRESSES IN MOST CASES OF MODERATE AND SEVERE DISEASE SPON REGRESSION CAN OCCUR IN UP TO 58% OF MILDER CASES NATURAL HISTORY IS STILL UNCHARTED TO A LARGE EXTENT

HOWEVER---MEDICAL TREATMENTS AND SURGERY FAIL TO ARREST DISEASE IN UP TO A THIRD COMBINATIONS OF TREATMENTS HAVE ALSO FAILED TO CONTROL DISEASE FOR INDEFINITE PERIODS WHEN FOLLOWED UP PREGNANCY HAS A VARIABLE EFFECT ON ENDOMETRIOSISPERSISTENCE, REGRESSION AND PROGRESSION

AND ALSO--------ENDOMETRIOSIS MAY OCCUR IN THE EARLY MENOPAUSE, USUALLY IN ASSOCIATION WITH HRT LAPAROSCOPIC ABLATION OF VISIBLE ENDO IN INFERTILE WOMEN IS ASSOC WITH SIGNIFICANTLY INCREASED FERTILITY RATES THERE IS NO DATA REGARDING EARLY INTERVENTION WRT PREVENTION

PREVALENCE
NOT PRECISELY KNOWN2-5% 20-40% OF WOMEN IN INFERTILE COUPLE RELATIONSHIPS VS 5% OF FERTILE WOMEN BUT ALSO FOUND IN 6-43% OF WOMEN UNDERGOING LAPAROSCOPIC STERILIZATION 52% OF TEENAGES WITH CPP SYNDROME

Familial association
Relative Risk to siblings 2.3 overall Relative Risk to sibs if severe endo 15

Risk factors
Single/nulliparous Early menarche Non oral contraception Non smoker shorter cycle/longer duration of flow Dysplastic naevus syndrome, melanoma

symptoms
90% 70% 75% 55% severe dysmenorrohoea chronic pelvic pain dyspareunia infertility

Infertility mechanisms
Adhesions distorsion Chronic salpingitis Increased PGs Cell mediated gamete inj Activated Increased macrophag prev. ABs Defective folliculogeni sis LUFFS

Altered Cytokines tubal motil

Fertilization hyperprolac failure tinaemia

Impaired Sperm Early spon Luteal oocyte pick phagocytos abortion phase up ed deficency

Treatment of pain
NSAIDS: all significantly better than placebo, studies vary which one is best Naproxen >mefanemic acid>aspirin Naproxen=ibuprofen Naproxen only drug with significant SEs

treatment of menstrual pain

Treatment level of evidence Simple analgesics 1 Herbal remedies 1 alcohol 2 Antidepressants/anxiolytics 2 OCPs 1 NSAIDS 3

ENDOMETRIOSIS PAIN
PSYCO-PHYSICAL TREATMENTSACCUPUNCTURE, MESSAGE, RELAXATION, TENS EXERCISE ANTI-OESTROGEN DRUGS LAPAROSCOPY/ OPEN SURGERY

LIMITATIONS OF DRUG THERAPY

ONLY SHRINKS SOME TYPES OF ENDOMETRIOSIS WHICH ARE OESTROGEN SENSITIVE IE RED AND BLISTER APPEARANCE NOT BROWN, BLACK AND WHITE SHRINKAGE NOT COMPLETE- USUALY LEAVES MICRO DISEASE RESULTS FOR INFERTILITY TREATMENT NO BETTER THAN NO TREATMENT DOES NOT DEAL WITH ADHESIONS

META-ANALYSIS MIN/MILD ENDOMETRIOSIS

PREG RATE NO TREAT DRUG THERAPY SURGERY IVF 44% 41% 65% 20 n 235 418 912 257 FOLLOW-UP 0.5-3 1- 5 1-6