Endometriosis :An Overview Presented in Endometriosis update in Delhi June (2016) Hotel Leela EB Guidelines RCOG: Evidence-based Clinical, 1999 Endometriosis and infertility. ASRM, 2004. ACOG. Endometriosis in adolescents, 2005. ESHRE guideline for the diagnosis and treatment of endometriosis, 2005. Endometriosis and infertility. ASRM, 2006. Endometriosis: diagnosis and management. Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013. ESHRE guideline: management of women with endometriosis,2014.

1. Endometriosis :
An Overview
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar

2. Presented in Endometriosis update
in Delhi June (2016) Hotel Leela

3. EB Guidelines
1. RCOG: Evidence-based Clinical, 1999
2. Endometriosis and infertility. ASRM, 2004.
3. ACOG. Endometriosis in adolescents, 2005.
4. ESHRE guideline for the diagnosis and treatment of endometriosis,
2005.
5. Endometriosis and infertility. ASRM, 2006.
6. Endometriosis: diagnosis and management.
7. Fertility: Assessment and Treatment for People with Fertility
Problems. NICE, 2013.
8. ESHRE guideline: management of women with
endometriosis,2014.

4. March
is
Endometriosis
Awareness
Month

5. ”
Definition
“Presence of endometrial tissue outside the lining of the uterine cavity
or
“Proliferation of endometrium in any site other than the uterine mucosa’’

6. • Age: common in reproductive period
• True Incidence Unknown: ?
• Does NOT Discriminate by Race.
• Histology: Endometrial Glands with Stroma
+/- Inflammatory Reaction.
• Heriditary (↑↑ among sisters).
Epidemiology

7. SITES
Pelvic
UTERINE
- Adenomyosis (50%)
EXTRAUTERINE:
- Ovary 30%
- Pelvic peritoneum 10%.
- F. tube.
- Vagina.
- Bladder & rectum.
- Pelvic colon.
- Ligaments
EXTRA PELVIC
• Umbilicus.
• Scars (Lap.).
• Lungs &
• pleura.
• Others. Sites

8. •Diagnostic Dilemma
•Debilitating Disease
•Progressive Disease
•Disease with “No Cure”
•H/O Multiple Operations
• A Gynaecologist’s dilemma

9. Delay to Diagnosis of
8 to 10 years is the RULE
Delay of
• 10 years in Germany and Austria
• 8 years in the UK and Spain,
• 7 years in Norway, Italy
• 4–5 years in Ireland and Belgium
INDIA--- ?

10. PREVALENCE
•10%
Prevalence is higher in women with
• Dysmenorrhea : upto 60%
• Dyspareunia : upto 44%
• Pelvic Pain : upto 80%

11. AGE AT DIAGNOSIS

12. RISK FACTORS (Odukoya & Cooke, 1996)
I- ASSOCIATED:
First or second degree
relation.
Menstrual cycle < 27 days.
Menstrual duration > 7 days.
Genital outflow obstruction.
II- INCONCLUSIVE:
Obesity,
Exercise,
Age at menarche,
uterine retroversion.
III- NOT ASSOCIATED:
Age
Race
Social class
duration of marriage
ICUD
Miscarriage

13. Predisposing Factors
1. Hyperoestrinism:
a) Fibroid & metropathia hemorrhagica.
b) Delayed marriage, infertility.
c) Oestrogen secreting tumours of the ovary e.g. granulosa
& theca cell tumours, or with prolonged oestrogen therapy.
2. Cervical Stenosis.
3. Insufflation ?
4. Curettage ?

14. Pathogenesis
I- Endometrial
implantation: Retrograde.
II Vascular & lymphatic.
Mechanical.
III- In situ development:
Coelomic metaplasia.
Induction.
IV- Immunological.
V- Composite.

15. Endometriosis is said to be
Estrogen dependent .
It is one of the major causative
factors in the development of
endometriosis.
Pathogenesis ??

16. Excess Estrogen stimulates
Inflammation
Invasion
Angiogenesis
Cell Proliferation
Adhesions Pain

17. DONNEZ ET AL (2003)
• Red lesions = Early endometriosis
• Black lesions = Advanced endometriosis
• White = Lesions are believed to be
- Healed endometriosis or
- Quiescent or latent lesions.

19. ASRM classification (1996)
• The only difference between the 1985 rAFS classification &
1996 ASRM classification is that the latter includes
information on the morphologic appearance of the disease.
• Red: red, red-pink & clear lesions
• White: white, yellow-brown, peritoneal defects, subovarian
adhesion
• Black: black & blue lesions.
• Denote percent of total described as
• R ….%, W ….% and B ….%.
• Total should equal 100%.

20. CLASSIFICATION
• The revised American Fertility Society (rAFS)
(1985)was produced to standardize the
documentation of findings in patients who
have pelvic pain & endometriosis.
• Staging Involves:
• 1. Location
• 2. Depth of Disease,
• 3. Extent of Adhesions.

22. P
E
R
I
T
O
N
E
U
M
ENDOMETRIOSIS < 1cm 1-3cm >3cm
SUPERFICIAL 1 2 4
DEEP 2 4 6
O
V
A
R
y
R SUPERFICIAL 1 2 4
DEEP 4 16 20
L SUPERFICIAL 1 2 4
DEEP 4 16 20

23. POSTERIOR
CULDESAC
OBLTTERATION
Partial Complete
4 40
O
V
A
R
Y
Adhesions <1/3 Enclosure 1/3 – 2/3
Enclosure
> 2/3 Enclosure
R Filmy 1 2 4
Dense 4 8 16
L Filmy 1 2 4
Dense 4 8 16
T
U
B
E
R Filmy 1 2 4
Dense 4◦ 8◦ 16
L Filmy 1 2 4
Dense 4◦ 8◦ 16

24. REVISED AFS (1985)
• Stage I (minimal) 1 – 5.
• Stage II (mild) 6 – 15.
• Stage III (moderate) 16 – 40.
• Stage IV (severe) > 40.

25. • Symptoms (history).
• Signs (Exam).
• Investigations.
• DD.
Diagnosis

26. Adenomyosis Extra uterine
endometriosis
Age About 40
years
About 30 years
Parity Multipara nullipara
Socioeconomic Low high
Diagnosis cont…

27. Symptoms
Infertility 40 % Dysmenorrhoea 60 %
Chronic
Pelvic
Pain 80%
Pain
Premenstrual
Intramenstrual
Postmenstrual
100%
Dyspareunia 45 %

28. IN WOMEN OF REPRODUCTIVE AGE WITH
NON-GYNAECOLOGICAL CYCLICAL SYMPTOMS
• Dyschezia
• Dysuria
• Haematuria
• Rectal bleeding
• Shoulder pain.

29. Pelvic examination may reveal:
1. Pelvic tenderness.
2. Fixed retroverted uterus.
3. Nodularity of the Douglas pouch and
uterosacral ligaments.
4. Ovaries may be enlarged and tender .
5.Ovarian cyst may be detected.
Signs

30. • It should include both-
• Per Abdomen
• Per Speculum
• Per Vaginum
• Highest predictive value
• -- Menstruation
In all women suspected of
endometriosis

31. For adolescents and/or women without
previous sexual intercourse
• Rectal examination can be helpful for the
diagnosis of endometriosis.
• Only after Counselling and Verbal
Consent

32. Suspect Deep Endometriosis
• Women with (painful) induration and/or
nodules of the Rectovaginal wall found
during clinical examination or
• Visible vaginal nodules in the posterior
vaginal fornix

33. Consider Ovarian Endometriosis
Adnexal Masses
detected during clinical examination

34. Be Obsessed with Endometriosis
• In women suspected of the disease
even if the clinical examination is
NORMAL

35. INVESTIGATIONS:
INVASIVE DIAGNOSIS
I. Laparoscopy
II. Microlaparoscopy.
NON INVASIVE DIAGNOSIS.
• Imaging:
• U/S,
• MRI
III. Endometrial nerve fibers
IV. CA 125
V. Other.

36. LAPAROSCOPY
• GOLD STANDARD'
DIAGNOSTIC TEST
ADVANTAGES
(RCOG Grade B evidence)
1.Excludes other conditions e.g. ovarian cancer
2.Treatment of Endometriosis can be done at the
same time

37. Laproscopy & Histology– Gold
Standard
• Perform a laparoscopy to diagnose endometriosis
• Confirm a positive laparoscopy by histology, since positive
histology confirms the diagnosis of endometriosis even
though negative histology does not exclude it.
• Clinicians should obtain tissue for histology to exclude rare
instances of malignancy.

38. Transvaginal Ultrasound
• First-line investigational tool for suspected E
• Help diagnose
endometriomas,
bladder lesions, and
deep nodules such as those in the rectovaginal septum.
• Findings:
1.Anechoic to echogenic cysts
2.Masses containing multiple septations & solid tissue (Morane
&Older, 1996)
3.Cysts with low-level echoes: The commonest finding (95%)

39. Ovarian Endometrioma
Perform TVS
diagnose or to exclude an ovaria Endometrioma

40. Ultrasound features
• Ultrasound
characteristics in
premenopausal women
1.Ground Glass
echogenicity
2.one to four
compartments
3. NO PAPILLARY STRUCTURES
with detectable blood
flow

41. ULTRASOUND FOR RECTAL
ENDOMETRIOSIS
• TVS is highly operator dependent, and
experience is often lacking
• TVS is not recommended for diagnosis of
rectal endometriosis
• 3D ultrasound to diagnose rectovaginal
endometriosis is not well established

42. • Clinicians should assess ureter, bladder and
bowel involvement by additional imaging if
there is a suspicion based on
history or physical examination of deep
endometriosis.
• Barium enema, Transvaginal sonography
(TVS), Transrectal sonography and MRI
DEEP ENDOMETRIOSIS

43. Magnetic Resonance Imaging
????
• Clinicians should be aware that the
usefulness of magnetic resonance
imaging (MRI)
to diagnose Peritoneal Endometriosis
is not well established

44. Biomarkers ????
Clinicians are recommended not to use
biomarkers to diagnose endometriosis in
• endometrial tissue,
• menstrual or uterine fluids
• and/or immunological biomarkers, including
CA-125, in plasma, urine or serum

45. CA - 125
• No Serum Cancer Market has been studied in
greater detail than CA – 125
• It is identified in FT epithelium , Endometrium,
Endocervix, Pleura & Peritoneum
• Used to woman Cancer Evaluation & surveillance
Mild endometriosis
• sENSIVITY28%
Specificity90%
Stage III of IV Endometriosis ..S/S 90%

46. TREATMENT
• REVIEW
ESRH : 2014 EB Guidelines
Litereture : 2015 and 2016
• TREATMENT
1. Hormonal
2. Nutritional supplements, Complementary and alternative
treatments
3. Surgery
4. IUI and COS
5. ART
• Conclusion

47. Treatment : Consideration
• Age.
• Symptoms.
• Stage.
• Infertility.

48. Treatment (Rationale)
• Recognize Goals:
– Pain Management
– Preservation / Restoration of Fertility
• Discuss with Patient:
– Disease may be Chronic and Not Curable
– Optimal Treatment Unproven or Nonexistent

49. Current Treatment Options
SURGICAL MEDICAL
Removal of
Superfical and
Deep lesions
Adhesiolysis
To destroy or
prevent the lesions
( Not Possible)
Removal of
Chocolate cysts

50. When is Medical Treatment
Required ?
• First line treatment with chocolate cyst?
• First line treatment with superficial / deep
nodules?
• Role before surgery ?
• After surgery to prevent recurrence ?
• When surgery is not possible or refused ?
Full of
controversies

51. ESHRE
guidelines
2014
Best so far
For Treatment
Will answer all your queries

52. Laparoscopy
• Value:
It permits a “see and treat”
approach, although its
effectiveness may be limited by
the nature of the disease and the
surgeon's skill.

53. Limitations of surgery
Skill / Recurrence
LONG LEARNING CURVE
High risk of recurrence after surgery
25 % recurrence after 2 years
50 % at 5 years
40 – 80 % women have PAIN again
within 2 years of surgery

54. Medication Limitation
NSAIDs Lack of supporting evidence from controlled trials
GI side effects
Risk of gastric ulceration
Anti-ovulatory effect, when taken at mid cycle
Combined Oral Not approved for endomteriosis in most countries
Contraceptives Break through bleeding
GnRH Agonist Causes hot flushes, vaginal dryness and decreased libido
(Leuprolide) Acceleration of bone mass loss; increased risk of
osteoporosis
Use is limited upto 6 months
Androgens Adverse effect on lipid metabolism
(Danazol) Causes acne, Hirsuitism, vaginal dryness, edema, hot
flushes.
Associated with liver toxicity and breast atrophy
Progestins Lack of supporting evidence from controlled trials
Lack of dose finding data
Adverse impact on BMD

55. Aim of the hormonal therapy
(A) Pseudopregnancy :
1. Combined low - dose contraceptive pills(6 - 18
months to inhibit ovulation and menstruation and
induce decidualization to endometriosis tissues).
or
2. Progestins (to avoid oestrogen's side effects medroxy
progesterone acetate Depo medroxy progesterone
acetate (DMPA) can be given in a dose of 150 mg IM
every I - 3 months .

56. Aim of the hormonal therapy
(B) Pseudo menopause (induction of
amenorrhoea) by:
1. Danazol…Not used
2. Gn RH analogues.

57. GnRH-a
• Initially Stimulate FSH / LH Release.
• Down-Regulates GnRH Receptors–”Pseudo
menopause”.
• Long-Term Success Varies.
• Expensive.
• Use Limited by Hypo estrogenic Effects.
• May be Combined with Add-Back (? >1 Year ),
using E2/progesterone preparation.

58. GnRH-a
Add back (E2/progesterone preparation) :
• Reduce effect on bone mineral
density.
• Relieve hot flushes.

59. Endometriosis & IVF
• The presence of endometriosis does
not generally impair the results of IVF
but it increases the risk of infection.
• It is preferable not to cauterize
ovarian endometrium if IVF or ICSI is
indicated for fear of destruction of
ovarian tissues.

60. •Enigmatic Diseases
•Diagnostic Dilemma
•Debilitating Disease
•Progressive Disease
•Disease with “No Cure”
•H/O Multiple Operations
TAKE HOME MESSAGE

61. ADDRESS
11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
Helpline
9650588339,
011-22414049, 011-22058865
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
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