endometriosis (complete)
DESCRIPTION
A short ppt about Endometriosis based on...TRANSCRIPT
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ENDOMETRIOSISESHRE Guidelines on Endometriosis 2013
Justin W. Ng Sinco
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The following will be presented:• Case Presentation• Endometriosis• Definition• Epidemiology• Etiology
• Diagnosis• Treatment of Symptoms
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Case PresentationE.L., 30 year-old Gravida 1 Para 1 (1001) who came in with a chief complaint of hypogastric pain.
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E.L., 30 y.o.
• Gravida 1 Para 1 (1001)• Born on July 28, 1984 in Manila• Living in Camarin, Caloocan• Works as a Telecommunication specialist• Married
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History of Present Illness• Menarche at 13 years old• Subsequent menses were regular• 28 – 32 days interval
• 3 – 5 days duration• Moderate flow, 4 pads per day• (+) Dysmenorrhea
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History of Present Illness5 years PTC• Severe cyclic hypogastric pain• Worsened after menstruation
• Weakness and easy fatigability• No heavy bleeding, fever, dysuria, cough,
colds, headache
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History of Present Illness5 years PTC• Consult at private OB• Endometriotic cyst, left ovary• Polycystic ovaries• Folic Acid 5mg OD• Vitamin B complex OD• OCP for 3 months
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History of Present Illness3 years PTC• Danazol 200 mg 1 tab BID for 30 days (2012)• Injectable DMPA injected every three months
until November 2013
1 year PTC• Menstruation resumed regular cycle (May
2014)
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History of Present Illness
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History of Present Illness5 days PTC• Transvaginal Ultrasound
• Anteverted, normal-sized uterus with proliferative endometrium (0.6 cm)
• Right ovary is converted to a unilocular cyst with low to medium level echoes measuring 3.2x2.5x2cm
• Left ovary is converted to a unilocular cyst with low to medium level echoes measuring 2.8x2.6x2cm
• Cervix is unremarkable
• Dx: G1P1 (1001); AUB secondary to Bilateral Endometriotic Cysts
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Past Medical History
• Had mumps during childhood• Bronchial asthma: last attack 1995 –
1996• Non-hypertensive, non-diabetic• No known allergies to food and drugs• No history of prior hospitalization
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Family History
• Father, 58 years old, hypertensive and with bronchial asthma• Mother, 66 years old, apparently well• Siblings: 2 siblings, with one sibling with
hypertension, high cholesterol, and asthma • She denies other heredofamilial diseases
such as diabetes mellitus, malignancy, liver, kidney and lung disease.
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Personal & Social History• Eldest among 3 siblings• Graduate with an Engineering degree• Works as a Telecommunications specialist• Married for 7 years to a 30 year-old
network engineer• Has a 7 year-old daughter• Non-smoker, non-alcoholic beverage
drinker
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Gynecologic History
• Menarche at 13 years old• Subsequent menses were regular• 28 – 32 days interval
• 3 – 5 days duration• Moderate flow, 4 pads per day• (+) Dysmenorrhea, (+) Dyspareunia• (-) Post-coital bleeding, (-) Leukorrhea• Pap smear (2011) – normal
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Obstetrical History
• Gravida 1 Para 1 (1001)• Delivered on 2007, term living girl, BW
3000g, appropriate for gestational age, via NSD at Bernardino Hospital; no fetomaternal complications
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Method of Contraception• OCP (2010 to 2013)• DMPA (2013)
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Sexual History
• Coitarche: 22 years old• 1 sexual partner• Partner had 2 sexual partners
• In a monogamous relationship
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Review of Systems
• Unremarkable
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Physical Examination
• General Survey: Patient is conscious, coherent, not in cardiorespiratory distress, with the following vital signs:
BP: 100/70 PR: 74 bpm RR: 20 cpm Temperature: 36.8 C • HEENT: Anicteric sclera, pink palpebral
conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, stye on right lower lid• Neck: Supple neck, no neck vein
engorgement, no cervical lymphadenopathy
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Physical Examination
• Chest: Symmetrical chest expansion, no retractions, no lagging• Lungs: Vesicular breath sounds, no
crackles, no wheezes.• Heart: Adynamic precordium, normal
rate, regular rhythm, no murmurs• Breast: Symmetrical contour, no
dimpling, no palpable mass, no tenderness, no abnormal nipple discharge
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Physical Examination
• Abdomen: Flabby, soft, non-tender, normoactive bowel sounds, no mass• Speculum exam: clean looking cervix with
minimal whitish discharge• Internal exam: normal looking external
genitalia, parous introitous, vagina admits two fingers with ease, cervix firm and closed, unenlarged uterus, no adnexal mass nor tenderness• Extremities: No gross deformities, full and
equal pulses, no edema, no cyanosis• Skin: No active dermatoses
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Dysmenorrhea
Primary
• No pelvic pathology• Spasmodic
Secondary
• With pelvic pathology• Congestive
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Differential Diagnoses
Severe hypogastric pain (Dysmenorrhea)
Ectopic pregnancy
Pelvic Inflammatory Disease
Abortion
Endometriosis
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EndometriosisPresence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction (Kennedy, et al., 2005) ESHRE Guidelines 2013
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Endometriosis
Prevalence:• 2 – 10% of general female
population• Up to 50% in infertile women
Chronic pain
Infertility
Diminished QOL
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Endometriosis, Etiology
• Retrograde menstruation• Metaplastic conversion of coelomic
epithelium• Anatomic, Hematogenous or Lymphatic
dissemination• Immunologic dysfunction• Genetics
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Path
op
hysio
log
yMetaplasia Dissemination
Ectopic endometrial tissue
OvariesCul-de-sacBladderColonUreters
DiaphragmPeritoneumPosterior fornixLungs
ProgesteroneEstrogen
CytokinesProstaglandins
NeovascularizationFibrosis
INFERTILITYPAIN
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Diagnosis
• History• Physical Examination• Medical Technology
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Signs & Symptoms
Gynecologic
• Dysmenorrhea• Non-cyclical pelvic
pain• Deep dyspareunia• Infertility• Fatigue in the
presence of AOTA
Non-gynecologic
• Dyschezia• Dysuria• Hematuria• Rectal bleeding• Shoulder pain
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Physical Examination
• Speculum examination• Bimanual palpation• Rectovaginal palpation• Abdomen & Pelvis
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Physical Examination
• Induration and/or nodules of the rectovaginal wall, or visible vaginal nodules in the posterior vaginal fornix : Deep endometriosis
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Physical Examination
• Adnexal mass: Ovarian endometrioma
• Normal clinical examination does not rule out disease
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• Laparoscopy with histopathology: Gold standard
• Laparoscopy• Transvaginal ultrasonography• 3D sonography• MRI• Biomarkers
Medical Technology
Histology (Ovarian endometrioma/Deep infilitrating disease) to rule-out malignancy
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Transvaginal ultrasound
Ground glass echogenicity and 1 to 4 compartments and no papillary structures with detectable blood flow
OvarianEndometrioma
From http://www.ultrasound-images.com/
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Transvaginal ultrasound, E.L.• Right ovary is converted to a unilocular
cyst with low to medium level echoes measuring 3.2x2.5x2cm• Left ovary is converted to a unilocular
cyst with low to medium level echoes measuring 2.8x2.6x2cm
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Additional Imaging
If with suspicion of deep endometriosis:• Bowel : Barium enema, Transvaginal or
Transrectal UTZ• Bladder : Transvaginal UTZ with full
bladder, Cystoscopy• Ureter : MRI, CT Urogram
Sensitive > Specific
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Treatment Goals
• Relief of pain• Fertility, if wanted
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Admitting DiagnosisGravida 1 Para 1 (1001)
Secondary dysmenorrhea probably secondary to bilateral endometriotic cysts
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Pain Management
• Counselling plus• Analgesics• Combined hormonal contraceptives• Progestagens
• Surgery
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Hormonal Therapies
Hormonal contraceptives
Progestagens
Anti-progestogens
GnRH agonist
Patient preference
Side effects
Efficacy
Cost
Availability
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Hormonal Contraceptives
Dyspareunia
Dysmenorrhea
Non-menstrual pain
Chronic pelvic pain
Combined hormonal contraceptive
Combined oral contraceptive pills
Vaginal contraceptive ring or Transdermal patch
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Progestagens & Anti-progestagens• Medroxyprogesterone acetate (oral or
depot)• Dienogest• Cyproterone acetate• Norethisterone acetate• Danazol• LNG-IUS• Gestrinone
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GnRH agonists
• Nafarelin• Leuprolide• Buserelin• Goserelin• Triptorelin
Hormonal add-back therapy
Caution in young & adolescent women
+
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Aromatase Inhibitors
• For rectovaginal endometriosis refractory to other medical or surgical treatment
Aromatase Inhibitor
OCPProgestagenGnRH agonist
+
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Analgesics
• NSAIDs or other analgesics may be given
• Discuss risks• Gastric ulceration• Inhibition of ovulation• Cardiovascular disease
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Surgery
1. Operative laparoscopy• Ablation vs. Excision
• Equal effectiveness
2. Interruption of Pelvic Nerve Pathways• Laparoscopic Uterosacral Nerve Ablation
(LUNA)• Presacral Neurectomy
3. Ovarian endometrioma• Cystectomy vs. Drainage & Coagulation• CO2 Laser Vaporization
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Surgery
4. Deep Endometriosis• Surgical removal• Referral to centre of expertise
5. Hysterectomy• Hysterectomy + oophorectomy + removal of
endometrial lesions• Women with completed family; failed to
respond to conservative treatments
6. Adhesion Prevention• Oxidized regenerated cellulose• Other anti-adhesion agents
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Pre-operative hormonal treatment• Alleviates symptoms before the surgery• No change in outcome of surgery
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Post-operative hormonal treatment• Short-term vs. Long-term• Long-term therapy• Secondary prevention:
• Prevent recurrence of pain symptoms• Prevent recurrence of disease
• LNG-IUS or Combined hormonal contraceptive for at least 18 – 24 months
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Extragenital Endometriosis• Surgical removal• Medical treatment
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Non-medical strategies
• Supplements and alternative medicine are not recommended.
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PlanPatient is for Laparoscopic bilateral oophorocystectomy with chromopertubation
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Plan
• For Laparoscopic bilateral oophorocystectomy with chromopertubation• NPO 6 hours prior to OR
• IVF once on NPO: 1L D5LR for 8 hours• For Blood typing• Give Cefuroxime 1.5 g TIV (-) ANST 1
hour prior to OR
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Course in the Ward
• 2nd Hospital Day: Patient underwent Laparoscopy, surgical with bilateral partial oophorectomy, chromopertubation and electrofulguration of endometriotic implants• Patient was discharged improved on the
4th hospital day.
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Laboratory Results
• Blood type: “A+”• Histopathologic report of the bilateral
ovarian cysts: results pending
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Laboratory Results
• CBC• Hgb 150• Hct 0.43• Platelet count 351• WBC 9.5 (0.65,0.23,0.67,0.04)
• Urinalysis• Yellow/Hazy/6.0/1.015/Neg/Neg/1-2/0-2
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Laboratory Results
• FBS 5.8• BUN 3.85• Crea 64.7• SGPT 19.7• SGOT 13.8• Na 139• K 4.4• Ca 1.10
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Laboratory Results
• CXR: Normal• ECG: Sinus rhythm
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Operation Technique
• Ovarian epithelium covering the cysts were excised; edges of the cyst were stripped from the normal ovarian tissue.
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Intra-operative findings
• No ascites. Liver, spleen, subdiaphragmatic surface and bowel were smooth• Uterine corpus was retroverted with smooth,
pinkish serosa. Posterior cul-de-sac has multiple endometriotic implants.• Left ovary was cystically enlarged to 5x5cm
with a unilocular cyst measuring 3x2cm exuding chocolate-brown fluid• Right ovary was likewise enlarged to 4x3cm
with a 1 cm cystic mass exuding chocolate-brown fluid
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Intra-operative findings
• Both fallopian tubes were grossly normal with egress of methylene blue on chromopertubation. The rest of the abdomino-pelvic organs are grossly normal
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Post-operative DiagnosisGravida 1 Para 1 (1001)
Pelvic endometriosis AFS Stage III with bilateral endometrioma
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Treatment of Infertility
• Medical• Surgical• Medical adjunct to surgery• Alternative treatments
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Hormonal therapy
• Not effective
• Not recommended
Adjunct Hormonal therapy
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Surgery
• Operative laparoscopy + adhesiolysis
• CO2 Laser vaporization vs. Monopolar electrocoagulation• Excision of endometrioma capsule• Counselling
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Non-medical strategies
• Supplements and alternative medicine are not recommended.
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Assisted reproduction
• Intrauterine insemination with controlled ovarian stimulation within 6 months after surgical treatment• Assisted reproductive technology
(IVS/ICSI) is recommended• GnRH agonist for 3 to 6 months prior
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Menopause & Endometriosis• Estrogen/Progestagen therapy or
Tibolone reduces menopausal symptoms in surgically-induced menopause• Given at least up to the age of natural
menopause
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Asymptomatic Endometriosis• Incidental findings of ectopic foci with no
pelvic pain or infertility.• Surgical excision and ablation are not
recommended
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Prevention of Endometriosis• Etiology is unknown, thus primary
prevention is uncertain• Oral contraceptives : uncertain• Exercise : uncertain