[DISORDERS OF THE REPRODUCTIVE SYSTEM] October 5, 2013

ENDOMETRIOSIS
A. Definition - It refers to the presence of the endometrial tissue in extrauterine sites. The most common sites for endometriosis includes the ovary, fallopian tubes, uterine ligaments, rectovaginal septum, umbilicus, vagina, vulva and in the hernial sac. B. Etiology and Risk Factors It has NO single, clearly identifiable cause THEORIES OF CAUSATION: Hormonal influence - The initial genesis of endometriosis, its further development depends on the presence of hormones, mainly estrogen. Endometriosis is rarely seen before puberty and it regresses after menopause. Hormones with antiestrogenic activity also suppress endometriosis and are used therapeutically. Retrograde Menstruation backward movement of endometrial cells through the fallopian tubes out into the abdomen Lymphatic or Vascular spread Immunological factor - The peritoneal fluid in endometriosis shows the presence of macrophages and natural killer (NK) cells. Impaired T cell and NK cell activity and altered immunology. Risk factors include: Age 30-40 Family History One or more relatives (The mother, aunt, sister) had endometriosis Early menarche Short menstrual cycles (< 27 days) Heavy bleeding during menses Delayed childbearing Infertility Defects in the uterus or fallopian tubes C. Epidemiology a. Incidence and Prevalence Endometriosis is estimated to affect over one million women (estimates range from 3% to 18% of women) in the United States. Between 20% to 50% of women being treated for infertility have endometriosis Up to 80% of women with chronic pelvic pain may be affected. Endometriosis is rare in postmenopausal women. b. Age

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Most cases of endometriosis are diagnosed in women aged around 25 to 35 years c. Race Endometriosis is more commonly found in white women as compared with African American and Asian women Studies further suggest that endometriosis is most common in taller, thin women with a low body mass index (BMI) D. Symptoms The primary symptom of endometriosis is pelvic pain. Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain. Pain with intercourse (dyspareunia). Pain during or after sex is common with endometriosis. Pain with bowel movements or urination. Most likely to experience these symptoms during your period. Excessive bleeding. May experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia). Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility. Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods. The severity of the pain isn't necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have extensive pain, while others with advanced endometriosis may have little pain or even no pain at all. Based on the history and presenting signs and symptoms Tests to check for physical clues of endometriosis include: Pelvic exam. During a pelvic exam, your doctor manually feels (palpates) areas in your pelvis for abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it's not possible to feel small areas of endometriosis, unless they've caused a cyst to form. Ultrasound. This test uses high-frequency sound waves to create images of the inside of your body. To capture the images, a device called a transducer is either pressed against your abdominal skin or inserted into your vagina (transvaginal ultrasound). Both types of ultrasound may be done to get the best view of your reproductive organs. Ultrasound imaging won't definitively tell your doctor

E. Diagnosis

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whether you have endometriosis, but it can identify cysts associated with endometriosis (endometriomas). Laparoscopy. Laparoscopy is the most common and the golden standard surgical procedure for the diagnosis of endometriosis. Medical management is usually tried first. But to be certain you have endometriosis, your doctor may refer you to a surgeon to look inside your abdomen for signs of endometriosis using a surgical procedure called laparoscopy. While you're under general anesthesia, your surgeon makes a tiny incision near your navel and inserts a slender viewing instrument (laparoscope), looking for endometrial tissue outside the uterus. He or she may take samples of tissue (biopsy). Laparoscopy can provide information about the location, extent and size of the endometrial implants to help determine the best treatment options. F. Treatment PHARMACOLOGIC MANAGEMENT: Nonsteroidal anti-inflammatory drugs or NSAIDs (such as ibuprofen or naproxen sodium) are commonly prescribed to help relieve pelvic pain and menstrual cramping. If they work to control pain, no other procedures or medical treatments are needed. If they do not relieve the pain, additional evaluation and treatment generally occur. Gonadotropin-releasing hormone analogs (GnRH analogs) Gonadotropin-releasing hormone analogs (GnRH analogs) have been effectively used to relieve pain and reduce the size of endometriosis implants. These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available. Oral contraceptive pills - Oral contraceptive pills (estrogen and progesterone in combination) are also sometimes used to treat endometriosis. The most common combination used is in the form of the oral contraceptive pill (OCP). Continuous use in this manner will free a woman of having any menstrual periods at all. Occasionally, weight gain, breast tenderness, nausea, and irregular bleeding are mild side effects. Oral contraceptive pills are usually well-tolerated in women with endometriosis. Progestins - Progestins [for example, medroxyprogesterone acetate (Provera, Cycrin, Amen), norethindrone acetate, norgestrel acetate (Ovrette)] are more potent than birth control pills and are recommended for women who do not obtain pain relief from or cannot take a birth control pill.

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Side effects are more common and include: breast tenderness, bloating, weight gain, irregular uterine bleeding, and depression. Since the absence of menstruation (amenorrhea) induced by high doses of progestins can last many months after cessation of therapy, these drugs are not recommended for women planning pregnancy.

Danazol (Danocrine) Danazol (Danocrine) is a synthetic drug that creates a high androgen (male type hormone) and low estrogen hormonal environment by interfering with ovulation and ovarian production of estrogen. Eighty percent of women who take this drug will have pain relief and shrinkage of endometriosis implants, but up to 75% of women develop side effects from the drug. Side effects can include: weight gain, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, and mood changes. All of these changes are reversible, except for voice changes; but the return to normal may take many months. Danazol should not be taken by women with certain types of liver, kidney, and heart conditions. Aromatase inhibitors A newer approach to the treatment of endometriosis has involved the administration of drugs known as aromatase inhibitors (for example,anastrozole [Arimidex] and letrozole [Femara]). These drugs act by interrupting local estrogen formation within the endometriosis implants themselves. They also inhibit estrogen production in the ovary, brain, and other sources, such as adipose tissue. Research is still ongoing to characterize the effectiveness of aromatase inhibitors in the management of endometriosis. Aromatase inhibitors cause significant bone loss with prolonged use

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and cannot be used alone without other medications such as GnRH agonists or combination of oral contraceptives in premenopausal women because they stimulate development of multiple follicles at ovulation. G. Surgical Management Surgery. Surgery is usually the best choice for women with severe endometriosis many growths, a great deal of pain, or fertility problems. There are both minor and more complex surgeries that can help. The doctor might suggest one of the following:

Laparoscopy can be used to diagnose and treat endometriosis. During this surgery, doctors remove growths and scar tissue or burn them away. The goal is to treat the endometriosis without harming the healthy tissue around it. Women recover from laparoscopy much faster than from major abdominal surgery. Laparotomy or major abdominal surgery that involves a much larger cut in the abdomen than with laparoscopy. This allows the doctor to reach and remove growths of endometriosis in the pelvis or abdomen. Hysterectomy is a surgery in which the doctor removes the uterus. Removing the ovaries as well can help ensure that endometriosis will not return. This is done when the endometriosis has severely damaged these organs. A woman cannot get pregnant after this surgery, so it should only be considered as a last resort.

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PATHOPHYSIOLOGY OF ENDOMETRIOSIS
RISK FACTORS: Family History One or more relatives (The mother, aunt, sister) had endometriosis Early menarche Short menstrual cycles (< 27 days) Heavy bleeding during menses Delayed childbearing Infertility Defects in the uterus or fallopian tubes

ETIOLOGY: UNKNOWN THEORIES:

Hormonal influence Retrograde Menstruation Lymphatic or Vascular spread Immunological factor

MENSTRUAL CYCLE: ESTROGEN LEVEL HORMONAL INFLUENCE

Thickening of the endometrial lining in preparation for the fertilization of egg

If the egg is not fertilized, it disintegrates causing the hormones to drop

Levels of Estrogen and Progesterone

Shedding of endometrial lining in the form of menstrual blood

Regurgitation from the fallopian tubes

RETROGRADE MENSTRUATION

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Vascular

/ dissemination of
the endometrial tissue Endometrial cells deposited outside the uterus implant on structures within the cavity

LYMPHATIC OR VASCULAR SPREAD

Endometrium build up
Continuously responds to menstrual cycle stimulation More cells attach to pelvic structures

BLEEDING

INFLAMMATION

SCARRING

Infertility

ADHESION PHARMACOLOGIC MNGT: Nonsteroidal antiinflammatory drugs or NSAIDs Gonadotropin-releasing hormone analogs (GnRH analogs) Danazol (Danocrine) Aromatase inhibitors S/SX: Dysmenorrhea Chronic pelvic pain Dyspareunia Dysuria

PAIN