classification of endometriosis/staging/management

classification of endometriosis

1. Endometriosis

2. Endometriosis May Be Categorized Into Three Entities: Peritoneal endometriosis, ovarian endometriotic cysts (endometrioma) Deep endometriosis (DE)

3. Deep endometriosis Endometrial-like Tissue With A Depth Of More Than 5 mm

4. Stage I (1-5 points)Minimal Few superficial implants Stage II (6-15 points)Mild More and deeper implants Stage II(16-40p)Moderate Many deep implants Small cysts on one or both ovaries Presence of filmy adhesions Stage IV (>40 points) Severe Many deep implants Large cysts on one or both ovaries Many dense adhesions

5. MINIMAL: No clinical symptoms Small spots of endometriosis at Laparoscopy CLASSIFICATION: American Fertility Society

6. MILD Scattered fresh superficial lesions. No scarring or retraction. No adnexal adhesions

7. MODERATE Ovaries are involved Endometrioma < 2 cm. Minimal Peri tubal and Peri ovarian adhesions

8. SEVERE >2 CM Endometrioma size Dense peri tubal and peri ovarian adhesions + restricted mobility + may be bowel and bladder involvement.

9. TREATMENT Medical Surgical Combination Depends on: severity of disease Fertility needs age of patient and parity

10. Asymptomatic Endometriosis Medical treatment not required Lesions seen incidentally– does not indicate excision or ablation

11. MEDICAL MANAGEMENT Pain – NSAID, Analgesics HORMONAL TREATMENT Reduces pain Shared decision and counselling Combined OCP – oral, transdermal, vaginal ring Continuous Combined OCP LNG/ Etonorgestrel releasing IUS Implants  Decidualisation  Atrophy

12. Other options-medical management Danazol 200 mg 3 times x 6-9 months GnRH analogues 3-6 months with add back therapy Aromatase inhibitors daily for 6 months with or without hormones Ru 486 – 50 mg daily for 3 months GnRH antagonist

13. Conservative surgery: Laparoscopy – Excision of lesion Cauterisation / Laser vaporization of implants Resection of Chocolate cyst – Cystectomy (Minimise ovarian damage Post-op hormone therapy) Adhesiolysis LUNA Presacral neurectomy SURGICAL TREATMENT

14. Deep Infiltrating Endometriosis

15. Definitive Surgery ? Ovarian conservation In DIE & severe cases hysterectomy and removal of all visible endometriotic tissue can be done. BSO may result in improved pain relief & reduced chances of future surgery . (RCOG guidelines) In cases with normal ovaries, hysterectomy with ovarian conservation and removal of endometriotic lesions should be considered. ( ACOG guidelines 2010) TAH- BSO is reserved for women with debilitating symptoms ,who have completed childbearing & other therapies have failed. ( ASRM &Canada OBG Society,2010)