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|Posted By : Dr.Parul Kotdawala, MD, FICOG, FICMCH|
|Posted On : 19 Oct 2007 (Total Views : 4839)|
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Endometriosis is being increasingly detected in clinical practice. Various lifestyle & diet factors have contributed to this. Alcohol and Caffeine intake (coffee, tea, chocolates & cola drinks) increase the chances of developing endometriosis. ?Gluten Intolerance (intolerance to wheat products)? is also implicated to predispose to endometriosis. The optimum BMI for achieving pregnancy is 23.5 and women dieting to keep a BMI at 22 or less run the risk of developing endometriosis. The stress at work & resultant skipping of meals lead to disturbances in ovarian hormonal milieu leading to higher rates of endometriosis. Although the Intra vaginal Tampons (dioxin) are blamed for endometriosis, adequate data is lacking.
An appraisal of the ?Timeline? in endometriosis management may help our perspective;
- The early detection has become possible only after the advent of laparoscopy: 25?30 yrs
- Classifications & therapeutic consensus emerged only in last 20 yrs
- Operative endoscopy evolved in last 2 decades (more so in 10 yrs) & still a developing modality
- Danazol, GnRH analogues - available since last 10-20 yrs
These are still early days & the final words are yet to crystallize! Here are some tips aimed at facilitating colleagues in managing endometriosis in their practice;
1. How can you diagnose (or rule out) endometriosis with reasonable accuracy?
The only way to accurately diagnose endometriosis is the visual detection of lesion ? either a surface lesion, endometrioid (chocolate) cyst or a recto-vaginal nodule - either at laparoscopy or at laparotomy. Signs & symptoms (pain & infertility) have too much of crossover with other pathologies, and laboratory or imaging investigations are significantly inaccurate. Histopathology examination of biopsy from the visible lesions confirms the evidence of endometriosis in only 50%, as most of these are burnt out remnants.
RCOG ? Green Top Guidelines mention ?Laparoscopy is the 'gold standard' diagnostic test in endometriosis while looking for all types & stages of endometriosis?
2. When to investigate for endometriosis?
In infertile women ? an unexplained infertility of more than 12 months in <35 age - should undergo laparoscopy. The reason for this dictum is that approximately 30% patients with endometriosis have no symptoms. Women of 35+ age should undergo laparoscopy after 6 months of infertility, as their "ovarian reserves" are limited, and this precludes a more prolonged "expectant" therapy.
Among young girls having pain & dysmenorrhea compromising their routine activities & which are not relieved by analgesics for six months, a diagnostic laparoscopy is in order as avoiding a treatment may affect the reproductive career adversely. In women having pain there is a role of therapeutic trial of medicines!
3. What is the role of CA ? 125 in endometriosis management?
CA - 125 levels increase in endometriosis, but the rise may not correlate with the extent of the disease. A lady with mild disease may show higher values & a woman with severe endometriosis may not show a similar rise in CA 125 levels. Its major role is in periodic monitoring of medical therapy & falling levels suggest success of the medical therapy. A recent study has suggested that a preoperative value of 65+ is strongly correlated with the presence of adhesions involving the endometriotic foci.
4. Does the decision to start treatment depend on the stage/grade of endometriosis?
No, the decision to initiate treatment is based on symptoms suffered by the patient e.g. Infertility &/or pain. A mild disease may manifest as a long standing infertility or causing severe pain & the severe endometriosis may not produce any symptoms! The extent of treatment depends on the primary symptom, level of anatomic distortion, completion of childbearing function etc.
5. Location & type of endometriosis & their management;
Excision or destruction of the endometriotic tissues are the basis of surgical management & lead to significant improvement in symptoms. A surface endometriosis may be treated with electro-coagulation by monopolar or bipolar current. A chocolate cyst (often described as ovarian endometrioma) needs excision by cystectomy. Only in a subset of patients the cyst may be drained & the active lesions in the lining may be destroyed in situ by electrocautery when the lining is densely adhering to the ovarian stroma. Presence of a rectovaginal nodule requires complete excision as it is likely to produce intense dyspareunia.
6. Does the removal of cyst lining lead to loss of follicles & reduced ovarian reserve?
No, histological studies of the cyst lining have shown that it is predominantly fibrous tissue & only an occasional follicle is the detected in the cyst lining. But leaving behind the cyst wall, one increases the chances of a recurrence of disease. Laparoscopic cystectomy may offer better results with regard to cumulative post-op pregnancy rates compared with drainage & coagulation in the management of endometriomas
7. Should mild endometriosis be treated actively in infertile women?
Yes. Surveys have shown the presence of endometriosis at the time of Tubal ligation in 2-5% of cases whereas among infertile women the incidence of endometriosis is quoted between 25-50%. On average less than 10% women in general population are infertile, but 30-40% women with endometriosis are infertile.
(suggested reading: Laparoscopic surgery in infertile women with minimal or mild endometriosis Marcoux S et al. Canadian Collaborative Group on Endometriosis; N Eng J Med 1997;337:217-22)
8. Endometriosis & infertility management - options are medical, surgical & ART
-For endometriosis-associated infertility, medical therapy seems to have no value alone.
-Surgical therapy is beneficial for all stages of diseases.
-For early endometriosis: Surgery and/or super ovulation with IUI as first-line treatment
-For more advanced disease with tubal damage: surgery or IVF are options.
-For the most advanced cases: IVF preceded by 3 mths of medical treatment is advised.
9. Role of medical management
In endometriosis the role of medical management is restricted to cases with mild disease & having pain. Post operative use in severe cases is also warranted. Progestins, Danazol, GnRH agonists are all effective, but the beneficial effects disappear soon after cessation of therapy. If the therapy is given for more then 3 months, an addition of calcium to prevent osteoporosis is vital, especially in GnRH therapy.
10. Scope of surgical management
-Diagnosis of endometriosis
-Excision of implants, if this is not possible than destruction of implants in situ
-Minimal damage to healthy tissue to reduce post-op adhesions
-Adhesiolysis & anatomical correction of distortions
-Treat the primary pathology predisposing to endometriosis e.g. fibroid, septate uterus
11. Laparoscopy vs laparotomy in surgical management:
Treatment principles are the same for either route, but certain differences exist. Laparoscopy provides better vision as posterior area is difficult to access in a laparotomy. Magnification, Illumination, less drying & cooling of tissues, reduced exposure to air / infection, scar size & possibility of repeated surgery are points in favour of laparoscopy.
Loss of tactile sensation, long learning curve & high costs of equipments are issues against a widespread use of laparoscopy. Laparotomy should not be deprecated & in fact in severe disease it may be a preferred mode for a complete surgery, rather than partial surgery with laparoscopy.
12. Newer advances
a. Aromataze inhibitors: A recent publication (by
b. Lipiodol Flushing: An interesting study published in ?Fertility Society of
c. Photodynamic Therapy (PDT): Photodynamic therapy is based on the selective destruction of growing tissue resulting from interaction between photosensitizer, light & oxygen. A photosensitizer chemical is applied on the area where the endometriotic tissues will take it up. A wash with isotonic crystalloid solution will remove the chemical from the normal tissues. Now the infra-red light is thrown to the area & the endometriotic tissue will absorb more light energy as it is impregnated with photosentsitizer. This energy will destroy the lesion! Primarily used in cancer cases this therapy has shown great initial potential.
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