ppt on Endometriosis.Healthcare.Healthcare.pptx

PPt on Endometriosis

1. Endometriosis Presenter: Dr. Menoka Ferdous Moderator: Dr. Sweta

2. Overview Definition of Endometriosis Incidence Pathophysiology Diagnosis

3. Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis. The condition is one of unusual interest and, although it gives rise to tumor formation (that is, a swelling), it is not a neoplasm. This does not mean that ectopic endometrium cannot occasionally be the site for the development of a malignant growth, although this is uncommon. Definition-Endometriosis

4. Endometriosis occurs in two form In Extra uterine organs & tissues In uterine wall

5. In extrauterine endometriosis, ectopic endometrium is found, usually in other pelvic organs but sometimes in more remote sites. Recognition of extrauterine endometriosis began in the late 19th century, gaining attention over the last 50 years. Previously, pelvic endometriosis was often misdiagnosed as an inflammatory reaction due to associated adhesions. Endometriosis (Extrauterine)

6. Surgeons now recognize that evidence of current or past external endometriosis is found in 10-20% of laparotomies performed on white patients. It was once considered rare in African and Asian women, but its recognition is increasing in these populations due to enhanced diagnostic techniques like laparoscopy. Endometriosis (Extrauterine)

7. Endometriosis (Intrauterine)-Adenomyosis Adenomyosis involves invasion of the myometrium by endometrial glands. A minor degree of microscopic invasion by the basal endometrium is normal and can be exaggerated in hyperplastic endometrium.

8. For a diagnosis of adenomyosis, penetration must be at least one high power field from the basal endometrium. When applying this criterion, adenomyosis is not as common as uterine leiomyomas, although all three conditions can coexist. Misleading claims suggest adenomyosis is found in 50% of all uteri removed. Endometriosis (Intrauterine)-Adenomyosis

9. Endometriosis- Common & Rare occurring sites

10. The prevalence is about 10 -15%. There are many variables to consider in order to to accurately appreciate its epidermiology . One should consider that endometriosis is diagnosed by laparoscopy hence access to health resources to allow this confirmed diagnosis can be very variable, but are critical. Is high amongst the sub-fertile women (30 - 45%) as based on diagnostic laparoscopy and laparotomy. Prevalence

11. Result: In symptomatic women examined with transvaginal ultrasound by an experienced ultrasound examiner, ovarian endometrioma and/or deep endometriosis was found in one of four women and adenomyosis in one of nine women. Deep endometriosis was present in one of 11 women. Despite having symptoms, half of the women had no abnormal ultrasound findings. Update in Prevalence

12. Risk Factors

13. Several theories have been posited to explain the pathogenesis. Principles theories are: Retrograde menstruation ( sampson's theory, 1927): There is retrograde flow of menstrual blood through the uterine tubes during menstruation. The endometrial fragments get implanted in the peritoneal surface of the pelvic organs (dependent sites, e.G. , Ovaries, uterosacral ligaments). Outflow tract obstruction in the genital tract is frequently found in women with endometriosis. Coelomic metaplasia (Meyer and Ivanoff ): Chronic irritation of the pelvic peritoneum by the menstrual blood cause coelomic metaplasia which results in endometriosis. Surface epithelium of the ovary can differentiate into different histological cell types. Pathogenesis

14. Direct implantation (iatrogenic) theory: according to the theory, the endometrial or decidual tissues start to grow in susceptible individual when implanted in the new sites. Iatrogenic dissemination explains the development of endometriotic implants at the scar tissues. Lymphatic and vascular theory ( halban , 1925): It may be possible for the normal endometrium to metastasize the pelvic lymph nodes (30%) through the draining lymphatic channels of the uterus. Vascular theory: Hematogenous spread of endometrium can explain endometriosis at distant sites such as lungs, arms or thighs Pathogenesis

15. Genetic and immunological theory: Women developing endometriosis have peritoneal macrophages that are larger and hyperactive. These cells secrete multiple growth factors and cytokines to stimulate the development of endometriosis. Genetic basis and familial predisposition: Familial occurrence of endometriosis (mothers and daughters) is !Mown (seven-fold increase). It is with polygenic inheritance. Asian women have increased risk (nine-fold) of endometriosis Pathogenesis

16. Pathogenesis Autoimmune theory of endometriosis: Neoangiogenesis Upregulation of aromatase, cyclooxygenase-2 (COX-2) activity with increased local estradiol and PGE2 concentration. Down regulation of 17-p hsd2 in the stromal cells In endometriosis. Down regulation of progesterone receptor-p Isoform and development of progesterone Resistance Increased mitotic activity of endometriotic cells With the presence of interleukins and growth factors. Proliferation of glands and stromal cells

17. Theories to explain endometriosis at different sites

18. Peritoneal fluid: Cytokines and growth factors

19. The endometrium (glands and stroma ) in the ectopic sites has got the potentiality to undergo changes under the action of ovarian hormones. Proliferative changes are constantly evidenced, the secretory changes are conspicuously absent. It may be due to deficiency of steroid receptors in the ectopic endometrium. Cyclic growth and shedding: continue till menopause Blood is irritant and it causes dense tissue reaction surrounding the lesion with ultimate fibrosis. Pathology

20. Deep lesions with penetration >5 mm are more progressive (DIE). When encysted, the cyst enlarges with cyclic bleeding. The serum gets absorbed in between the periods and the content inside becomes chocolate colored. And the cyst is called chocolate cyst. In spite of dense adhesions amongst the pelvic structures, the fallopian tubes remain patent. However the tuba-ovarian anatomic relationship may be disturbed. . Pathology

21. Patient profile: Affected patients are typically aged between 30 and 45. The median age of endometriosis is 33.2 years. Prevalence increases from the age of 15 years and the highest is around 44 years. Most are multi-parous or have had one or two children, with symptoms appearing long after childbirth. Most of the nulli-parous suffer from infertility due to Endometriosis. There is frequently a family history of endometriosis. Outflow tract obstruction is a significant cause in teenagers (10%). Symptoms of Pelvic endometriosis : Minimal or mild, Moderate, Severe or deeply infiltrating endometriosis (DIE). Clinical Features

22. About 25% of patients with endometriosis have no symptom, being accidentally discovered either during laparoscopy or laparotomy. Symptoms are not related with extent of lesion. Women with extensive endometriosis may remain asymptomatic. Whereas women with minimal endometriosis may suffer incapacitating chronic pelvic pain. Depth of penetration is more related to symptoms rather than the spread. Lesions penetrating more than 5 mm are responsible for pain, dysmenorrhea, and dyspareunia. Nonpigmented endometriotic lesions compared to the classic pigmented 'powder burns' lesions produce more prostaglandin F (PGF) and hence are more painful The symptoms are mostly related to the site of lesion. Common symptoms are: Pelvic pain, rectal pain, cyclic rectal bleeding, diarrhea, dyspareunia. Midline lesions are more symptom producing. Degree of pain is not related to the severity of endometriosis. Clinical Features-Symptoms

23. Dysmenorrhea (70%): there is progressively increasing secondary dysmenorrhea. Dyspareunia (20-40%): the dyspareunia is usually deep. Chronic pelvic pain: the pain varies from pelvic discomfort to lower abdominal pain or backache Abdominal pain: There may be variable degrees of abdominal pain around the periods. Abnormal uterine bleeding (AUB) (15-20%): Menorrhagia is the predominant abnormality. If the ovaries are also involved, polymenorrhea or epimenorrhagia may be pronounced. There may be premenstrual spotting. Infertility ( 40-60% ): Endometriosis is found in 30-45% of infertile women, whereas in about 40-50% patients with endometriosis suffer from infertility. Symptoms

24. Related to organs involved: Urinary-frequency, dysuria, hydronephrosis back pain or even hematuria. Sigmoid colon and rectum-painful defecation ( dyschezia ), diarrhea, constipation, rectal bleeding or even melena. Patient may also present with symptom s/o IBS. Chronic fatigue, perimenstrual symptoms (bowel, bladder). Hemoptysis (rarely), catamenial chest pain, hemothorax. Surgical scars-cyclical pain and bleeding. Other Symptoms

25. Chronic Pelvic pain Syndrome Widespread multifocal persistent pain Multiorgan pain & dysfunction No response to conventional treatment Fatigue, Sleep disorders, Memory Impairment Helplessness Hopelessness Depression Anxiety Poor Quality of life Nervous arousal

26. Causes of pain in endometriosis : Peritoneal inflammation (PGF, cytokines) Tissue necrosis Adhesion formation Nerve irritation due to deep penetration Release of local inflammatory mediators Endometrioma formation Causes of pain

27. A. Pelvic cavity: (a) Peritoneal fluid: inflammatory changes (b) Proliferation of microphages, and release of proinflammatory factors (c) Changes in peritoneal fluid that Alters sperm oocyte interaction (d) Distorted pelvic anatomy (Failure of ovum pickup) B. Ovaries: (a)Anovulation; (b) Oligo-ovulation; (c) Luteal phase Defect; (d) Reduced ovarian reserve (destruction by endometriosis and/or surgery); (e) Adhesions covering ovaries and Tubes; ( fl poor response to ovulation induction, COS and ART C. Uterus: (a) reduced endometrial receptivity; (bl implantation failure (c) resistance to progesterone D. Others: pelvic pain, dyspareunia Causes of subfertility with Endometriosis

28. Clinical Diagnosis Diagnosis is often based on classic symptoms: Progressively increasing secondary dysmenorrhea Dyspareunia Infertility Pelvic findings support the diagnosis: Speculum examination: Bluish powder-burn lesions on the cervix or posterior fornix Lesions may be tender and can bleed Bimanual examination: Nodularity in the pouch of douglas Nodular feel of the uterosacral ligaments Fixed retroverted uterus Unilateral or bilateral adnexal masses (chocolate cysts) Physical examination has poor sensitivity and specificity; many patients may show no abnormal findings.

29. Serum marker: Cancer antigen (CA) 125-a moderate elevation of serum CA 125 is noticed in patients with severe endometriosis. It is not specific for endometriosis. Monocyte Chemotactic Protein (MCP-1) Glycodelin (placental protein 14) is elevated in endometriosis. Levels also decrease with removal of the disease. Other predictive markers are interleukin-1 (lL-1) and interferon gamma. Investigation

30. Imaging: Ultrasonography: : Transabdominal ultrasound . Transvaginal scan (TVS) can detect ovarian endometriomas. TVS and endorectal ultrasound (ERUS) are found better for rectosigmoid endometriosis specially for diagnosis of deep infiltrating endometriosis (DIE). Magnetic resonance imaging (MRI): It is the best diagnostic tool , better resolution and soft tissue interfaces are well defined . Computed tomography (CT): It is better compared to ultrasonography in the diagnosis. Colonoscopy, rectosigmoidoscopy , and cystoscopy are done when respective organs are involved. Investigation

31. Laparoscopy: it is an important diagnostic tool Assessment of the lesion with site, size, and extent Biopsy can be taken at the same time Staging can be done Extent of adhesions could be recorded Opportunity to do laparoscopic surgery if needed On Laparoscopy Extent of the disease is assessed by point scoring system (ASRM-1996). Investigation

32. Laparoscopy or Laparotomy : The classic lesion of pelvic endometriosis may be as 'powder burns' or 'match stick' spots on the peritoneum of the pouch of Douglas. Biopsy confirmation of excised lesion is ideal but negative histology does not exclude it. Intravenous urography (IVU): It is useful in cases with deep infiltrating endometriosis (DIE) and suspected ureteric involvement. Investigation

33. Update in Diagnosis

34. ESHRE recommendation in Diagnosis

35. Staging The diagnosed endometriosis should be appropriately staged based on laparoscopic findings: To predict prognosis To choose therapy To evaluate the treatment protocol

36. American society of reproductive medicine (ASRM) scoring system of endometriosis

37. ENZIAN classification (2021)

38. No single classification system adequately classifies endometriosis although ASRM classification is most widely used. Endometriosis Fertility Index (EFI)- is surgical scoring system which is done to observe the extent of disease & plan for a management of subfertile patients, suffering from endometriosis.

39. Endometriosis Psychological Impact Endometrial wellbeing Social isolation Dyspareunia Infertility Intimate relationship Relationship difficulties & Breakdown Work Education Abseteelsm Negative Cognition Focus on pain symptoms Daily activities Physical functioning Mental health exacerbation Catastrophiaing Endometriosis Impact

40. Endometriosis is an enigmatic disease and diagnosis is usually delayed by an average of 6.7 years. Often the symptoms are vague & non specific. It can be a long-term condition, and can have a significant physical, sexual, psychological and social impact. Women may have complex needs and require long-term support. Whilst there still exists a great unmet clinical need for improving many aspects of the diagnosis of the disease and the treatment of endometriosis-associated symptoms Conclusion

41. Jeffcoate’s Principles of Gynaecology ; 8 th Edition. DC DUTTA'S TEXTBOOK OF Gynecology; 9 th Edition. ESHRE Guideline on Endometriosis’ 2022. NICE Guideline. Trends in Molecular medicine Journal Acta Obstetricia et Gynecologica Scandinavica Journal Endometriosis current topics in diagnosis and management Reference

42. Thank You