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The Modern Management of
Endometriosis
Malcolm Padwick
What is it ?
The presence of endometrial tissue outside
of the uterine cavity
• cul-de-sac
• rectovaginal septum
• surface of rectum
• fallopian tubes and ovaries
• uterosacral ligaments
• bladder
• pelvic side wall
Is it inherited?
• 6 to 8 fold increase risk in sisters
compared to unrelated women
• affected sisters are more likely to have
severe disease
• OXEGENE study ongoing
• ovarian cancer link
• racial
Aetiology
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Retrograde menstruation
tissue transplantation
peritoneal cell metaplasia
venous spread
lymphatic spread
immune failure
Incidence
• At sterilisation 2 to 5 % have
endometriosis
• 25 to 50 % of women investigated for
infertility
• estimated 5 million women in USA
• 6 to 7 % of all females
Endometriosis symptoms
dysmenorrhoea
pelvic pain
infertility
dyspareunia
menstrual irregularities
other cyclic bleeding
70%
40%
35%
33%
15%
1-2%
Endometriosis
Diagnosis
• laparoscopy
The natural progression
Lesions
Clear
Red
Black
mean age 21.5
mean age 31.9
disease is progressive in 47 - 64% of women
and in 20% of treated women (Redwine)
Endometriosis and Fertility
• 30 to 40 % of women with endometriosis
are infertile
• may be obvious anatomical abnormalities
• hormonal E2 reduced LH blunted
• multicystic ovaries
• Luteinized Unruptured Follicle X 3
• peritoneal fluid, macrophages, cytokines,
interferon C3, C4 are all increased
• plasma embryotoxic in 78% of cases
Endometriosis
Management options 1
Diagnostic laparoscopy
Drugs
• OCP
• Provera
• Danazol / Gestrinone
• GNRH analogues
Surgery
• Hysterectomy with BSO
Endometriosis and Fertility
Hormonal or antihormonal therapy has no beneficial
effect
on fertility either alone or as an adjunct to surgery
( RCOG recommendation)
only surgical ablation or excision of disease will
restore fertility ( RCOG recommendation)
Endometriosis
Management option 2
• Diagnostic laparoscopy proceeding to
immediate corrective surgery; LASER
and /or laparoscopic resection of
diseased tissue
Endometriosis
CO 2 LASER Vs Diathermy
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depth of destruction
accuracy
collateral / unseen damage
placebo effect
cost
Pelvic side wall
Endometriosis
Treatment by CO2 LASER
Classification
Pregnancies
Improved pain
I minimal
II mild
III moderate
IV severe
72%
60%
50%
44%
89%
87%
85%
80%
AFS
Del Pozo 1997
Women with pain
• Drug therapy may relieve inflammation and
reduce pain in early superficial disease but
corrective surgery +/- drug therapy is
preferable (Padwick 1999)
• rectovaginal, rectal and uterosacral lesions
always need surgery
• endometriomas always need surgery
• abnormal anatomy and adhesions always
need surgery
Rectal involvement
Endometriosis on the caecum
Endometriosis on the caecum
Endometrioma
LASER ablation of
endometriosis
• endometriosis not cured by medication
• surgery may cure the younger woman
Techniques
• ablate
• LUNA
• resect peritoneum
• ventrosuspension
Before
After
But what if ?
Requirements
• full RCOG accreditation
• MAS accreditation
– surgeon
– preceptor
– LASER certification
What to expect
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Overnight stay (98%)
3 puncture marks 5mm in length
Voltarol / oral analgesics
1 to 2 weeks off work
Mostly an immediate difference in pains
Benefits of fertility are immediate
West Herts Audit
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150 + women treated per year
> 500 women treated
> 95% diagnostic rate
No acute complications
No laparotomies
One late sepsis
Outcome measures ??
Conclusion
Endometriosis should be treated early and
aggressively by surgical destruction or
excision, ideally at laparoscopy. Drug
therapy which is expensive, largely
ineffective and has significant side-effects
should be reserved for selected cases
requiring post surgical maintenance
therapy.
Padwick 1999