ENDOMETRIOSIS pathway; ENDOMETRIOSIS pathway

ENDOMETRIOSIS

1. Endometriosis

2. Endometriosis Presence of Endometrial like tissues outside the uterus, it may induce chronic and inflammatory reaction Presence of Endometrial gland and stroma in an aberrant or heterotopic locations It is an estrogen- dependent inflammatory conditions that is primarily found in the pelvic peri

3. Symptoms Presence of Gynecological Symptoms Dysmenorrhea Non cyclical pelvic pain Dyspareunia Infertility Non-gynecological cyclical symptoms Dyschezia Dysuria Hematuria Rectal bleeding

4. Reference: Clinical Diagnosis of Endometriosis: A Call to Action - American Journal of Obstetrics and Gynecology (2019)

5. Clinical Examination Associated with Endometriosis Classic Pelvic Finding: Fixed, retroverted uterus , with scarring and tenderness posterior to the uterus Ovaries may be enlarged and tender and are often fixed to the broad ligament or lateral pelvic sidewall On speculum exam: May have endometriosis on cervix or upper vagina On IE: Lateral deviation of cervix in 15% of women with moderate to severe endometriosis

6. DEEP IINFILTRATING ENDOMETRIOSIS Can be considered in women with painful indurations and/ or nodules of the rectovaginal wall found during pelvic examination or vaginal nodules in the posterior vaginal fornix OVARIAN ENDOMETRIOMA It can be considered to physical examinations noted as adnexal masses

7. Imaging: Transvaginal Ultrasound No specific pattern; May help distinguish an endometrioma from other adnexal abnormalities. Sensitivity from 64% to 91%, with high specificity 89 to 100% Unilocular cyst with homogenous low level echogenicity of the cyst fluid (ground glass echogenicity) Transvaginal Ultrasound with Color Doppler Useful for ovarian endometrioma

8. Magnetic Resonance Imaging (MRI) Used in ultrasonographycally indeterminate pelvic masses and in the diagnosis of deep infiltrating endometriosis Sensitivity and specificity of approximately 91% to 95%.

9. Definitive Diagnosis of Endometriosis DIAGNOSTIC LAPAROSCOPY Definitive way to establish the diagnosis of endometriosis (classic powder burn, blue-black lesions) Important to systematically describe the extent of the pathology The focus was intended to provide characterization of disease extent for fertility and not for pain assessment The American Society for Reproductive Medicine – Revised Classification of Endometriosis

10. The American Society for Reproductive Medicine – Revised Classification of Endometriosis

11. St. I (1-5) Isolated superficial disease on peritoneum. No adhesions St. II (6-15) Scattered superficial disease on peritoneum and ovaries <5cm in aggregate, no adhesions St. III (16-40) Multifocal disease both superficial and invasive, with adhesions on fallopian tube and ovaries St. IV (>40) Multifocal disease both superficial and invasive, including large endometriomas, with adhesions, both filmy and dense involving fallopian tube, ovaries and cul de sac

12. Management SHORT TERM GOAL Relief of pain and Address Infertility problems LONG TERM GOAL Prevent recurrence and progression of the desease

13. Approach of Management MEDICAL MANAGEMENT Empiric management Goal is to address the endometriosis related pain SURGICAL MANAGEMENT Gol is to remove macroscopic endometriosis, restoration of normal anatomy and release of adhesions

14. Medical Therapy Suppression of lesions and associated pain thru menstrual suppression (ideally without inducing hypoestrogenism) Unfortunately, once suppressive therapy is stopped, symptoms tend to recur at variable rates. The recurrence rate following medical therapy is 5% to 15% in the first year and increases to 40% to 50% in 5 years. The choice of medical therapy should be individualized (adverse effects, side effects, cost of therapy, and expected patient compliance). medical therapy usually suppresses symptomatology and prevents progression of endometriosis, but it does not provide a long-lasting cure of the disease

15. Drug Class Drugs Dose Side Effects NSAIDs Ibuprofen Naproxen Mefenamic Acid 400mg every 4-6 hours 500mg initially then 250mg every 6-8 hrs GI Disturbances Progestin Norethindone acetate MPA DMPA Dienogest 15mg OD 30-50mg OD 150mg IM q 1-3 months 2mg OD > 2 years of use is associated with bone mass density decrease Estrogen- Progestin Daily single dose for 6-9 months GnRH Analogs Leuprolide 3.75mg IM / month Vaginal dryness, insomnia, flushes, decrease in mineral content Danazol Hypoestrogenic and hyperandrogenic effect 200mgtab QID in Day 5 for 6 months

16. Hormonal Treatment Oral Contraceptives Continuous daily for 6-12 months Continuous dose regimens are aimed at more complete suppression, with an advantage over cyclic use (Zorbas, 2015) It address the dysmenorrheal symptoms but no noted reduction on dyspareunia Progestin Medroxyprogesterone acetate (MPA), Norethisterone Acetate (NET) and Dienogest Dienogest – selective progestogen that causes anovulation, has an antiproliferative effect on endometrial cellsa nd may inhibit cytokine secretion; found to be as effective as GnRH agonists

17. Gonadotropin Releasing Hormone (GnRH) Agonist Inhibits FSH and LH Secretion and gives rise to profound suppression of ovulation leading to hypoestrogenic state Inhibits development, maintenance and growth of endometriosis GnRH agonist therapy improves symptoms in 75% to 90% of patients. Growth of endometriosis is arrested, diminished, or eliminated. The greatest therapeutic effects are seen when areas of endometriosis are less than 1 cm in diameter. Ovarian function usually returns to normal in 6 to 12 weeks after 6 months of GnRH agonist therapy.

18. “Add back” hormone replacement to reduce or eliminate the vasomotor symptoms and vaginal atrophy and also diminish or overcome the demineralization of bone. Add back therapy Not only reduce or eliminate adverse clinical and metabolic side effects associated with hypoestrogenism but also facilitate safe and effective prolongation of GnRH agonist therapy for up to 12 months. Additional agents that have been used for add back therapy are tibolone and raloxifene.

19. Surgical Approach Conservative Resection of implants, adhesiolysis, attempts to restore normal pelvic anatomy The approach is a minimally invasive surgery: LAPAROSCOPIC Goal: Preservation of reproductive organs and restoration of normal pelvic anatomy Definitive Removal of both ovaries, uterus, and all visible ectopic foci of endometriosis The approach could either be Laparoscopic or Laparotomy Removal of the ovaries may decrease the risk of disease recurrence, this should be balanced with the risks associated with removing the ovaries and therefore should be individualized based on the patient’s age, clinical presentation, and goals. Approximately one 1 out of 3 women will develop recurrent symptoms and subsequently have a second operation involving oophorectomy.

20. Referrences Comprehensive Gynecology 7 th edition Philippine Society of Reproductive Endocrinology and Infertility: Clinical Practice Guidelines on Endometriosis (2014)