Endometriosis is the presence of endometrial glands and stromas outside the uterine cavity.
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Endometriosis is a common gynaecological condition in about 10% of women and its pathogenesis is unknown. The most popular theory is that after retrograde menstruation the endometrial tissue sticks to and infiltrates the peritoneum and pelvic organs.
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Symptoms often include dysmennorhoea, chronic pelvic pain, dyspareunia, menorrhagia and infertility.
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Diagnosis
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History and examination findings often don't correlate well with surgical findings. The site and severity of symptoms is a poor guide to the presence of endometriosis (Vercellini). Endometriosis even if present may not be the cause of pain, and if found incidentally may produce no symptoms and therefore require no treatment.
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Other causes and risk factors for pelvic pain should be sought, investigated and managed such as irritable bowel syndrome and previous sexual assault and abuse.
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Ultrasound may detect ovarian cysts of endometriosis (endometrioma), but usually does not detect endometriosis in other sites. A negative ultrasound does not exclude disease.
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Definitive diagnosis is by laparoscopy - visualisation, biopsy and histology. The revised American Fertility Society (rAFS) staging system is in common usage with a grading system of minimal / mild / moderate / severe disease but has limitations with regard to management of pain symptoms.
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When endometriosis is found at laparoscopy an assessment of depth of endometriosis should be recorded as well as the distribution. Bowel involvement should also be noted to aid further treatment discussions and planning.
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Management
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The patient should be actively involved in deciding on a management plan. This should be based on management of symptoms and may include surgery, medication or a combination of the two. The aim is to decrease pain, limit recurrence and/or enhance fertility.
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Pain - medical therapy
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- Non steroidals, paracetomol
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- Intermittent pain relief can be an acceptable course of treatment for some women. They can be used alone or in conjunction with other therapies.
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Hormonal manipulation
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Various therapies have been tried for endometriosis. All are trying to cause cessation of menstruation. There is little difference between Progesterones and GnRH analogues in effectiveness of treating pain with endometriosis, however their side-affect profiles are very different (Farquar and Sutton). OCP has been shown to be less effective that other hormonal treatments in pain suppression.
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Oral Contraceptive Pill (OCP)
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There is certainly a place for women who have pain and are not wanting to conceive to be offered a trial of cyclical OCP for 3 months prior to investigation with laparoscopy in the setting of a normal ultrasound. The OCP can also be used as long term treatment for symptoms either taken cyclically or continuously (skipping the sugar pills).
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Common side effects include; nausea, vomitting, headaches, menstrual irregularities, weight change. There is also an increased risk of thrombo-embolic disease.
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Progestagens
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Can be administered in the form of tablets, injections, depo-injection, Mirena IUCD and have all been shown to be successful in treating the pain of endometriosis. A trial of one of these can also be considered prior to embarking on laparoscopy. Common side-affects include; weight change, depression, PMT, abnormal bleeding, amenorrhoea.
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Gonadotropin-releasing hormone (GnRH)
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Administered by implant or nasal spray.
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Caution must be used with GnRH analogues as they can produce significant menopausal side-affects that the patients find intolerable and if used long term (more than six months) carry the risk of irreversible bone mineral density loss. This risk can be reduced with the addition of 'Add-back' therapy in the form of HRT, although the safety of GnRH analogue used long-term has not been determined.
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Pain - surgery
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Laparoscopy and treatment of endometriosis is the mainstay of surgical treatment. Optimal treatment clearly reduces pain scores in many women (Garry). Patients need to be counselled about and aware of the risks of laparoscopy before embarking upon that course.
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Success rates for improving symptoms are about 75% at 12 months. Recurrence of symptoms long term is common.
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Removal of pelvic organs / pelvic clearance should be reserved for women who have found conservative surgery unsuccessful and understand that pelvic clearance may not cure their pain.
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Infertility - medical therapy
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There is no evidence that suppressive medical therapy improves fertility rates in women with endometriosis.
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Infertility - Surgery
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Surgical treatment of minimal-mild endometriosis may improve fertility (Sutton, Marcoux). Removal of endometriomas is usually performed prior to IVF treatment.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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