Transcript Treatment of pelvic pain due to endometriosis

Dr zahra asgari
Associated professor of ob/gyn
Endosurgeury
[email protected]
Arash hospital
TREATMENT
 Expectant management
 Medical management
 Surgical management
 Expectant management is considered
two groups of patients:
1.
women with no or minimal symptoms
2.
perimenopausal women.
for
MEDICAL TREATMENT
 pelvic pain and suspected endometriosis  empiric
medical therapy prior to establishing a definitive
diagnosis by laparoscopy
 analgesics and/or combined oral estrogen-progestin
contraceptives for women with no more than mild
pelvic pain
 GnRH agonist for those with moderate to severe pelvic
pain.
 80 to 90 percent of patients some improvement in
symptoms with medical therapy
 medical interventions neither enhance
fertility nor diminish endometriomas or
adhesions
 women with suspected endometriomas and
advanced stages of disease, or infertility,
are more appropriately managed surgically
INDICATIONS(diagnosis and management )
 ●Failure of medical therapy or contraindications to medical
therapy
 ●Need for a definitive diagnosis of endometriosis (definitive
diagnosis requires surgery to visualize and/or biopsy lesions)
 ●Exclude malignancy in an adnexal mass
 ●Treatment of infertility in selected women
 ●Obstruction of the urinary tract or bowel
SURGICAL PLANNING
 should be counseled about their options
 They should be counseled about the choice between
conservative or definitive surgery( conservative
treatment procedures are performed laparoscopically,
but extensive disease may require laparotomy)
Conservative versus definitive
surgery
 Conservative surgery is typically used as the initial surgical
treatment for endometriosis(excision or ablation of
endometriotic lesions with the intent of preserving the uterus
and as much ovarian tissue as possible), nerve transection
procedures
 Women with recurrent symptoms may be treated with either
repeat conservative surgery or definitive surgery.(hysterectomy
combined with bilateral salpingo-oophorectomy)
 women wish to preserve reproductive and endocrine function,
and thus, hysterectomy alone or hysterectomy plus unilateral
salpingo-oophorectomy is often performed for pain caused by
endometriosis
The choice between conservative
and definitive surgery
 efficacy and potential morbidity of the procedure
 the patient’s plans for future childbearing
 and patient preference.
 Definitive surgery is typically performed after medical
therapy and one or more conservative procedures have
failed(decide whether to remove or conserve the
ovaries)
Conservative surgery
advantages :effective( at least in
the short term)
associated with less morbidity
than definitive surgery
disadvantage :rate of recurrent
symptoms is higher than for
definitive surgery
 definitive surgery :
 perioperative complications and recovery
 hormonal function and body image
 hysterectomy is associated with a higher
complication rate than laparoscopic
treatment of endometriosis
 Some women who undergo hysterectomy
may experience regret or a change in body
image
In terms of efficacy, in the short
term, conservative surgery and
hysterectomy appear comparable
rate of reoperation for recurrent pain at
one year after either laparoscopic
treatment or hysterectomy was similar (0
to 5 percent)
 it appears that hysterectomy alone is an effective
treatment for pain symptoms of endometriosis.
 Oophorectomy likely increases the efficacy of
definitive surgery, but is also accompanied by the
quality of life issues and potential adverse health
effects of premature menopause
 There are no data to establish a specific age threshold
for which the benefit of oophorectomy for treatment
of endometriosis pain outweighs the risks of
premature menopause
counsel all women undergoing definitive surgery about
the risks and benefits of oophorectomy
 we tend to discourage
oophorectomy in women
younger than 40 years
 Women approaching the
average age of menopause
(51 years) are more likely to
choose oophorectomy
since they may reduce the
risk of recurrent pain
symptoms while losing
fewer years of hormonal
function
Suspicion of deep infiltrating
lesions or extrapelvic disease
 DIE: refers to lesions that penetrate to a depth of 5 mm
or more
 multifocal and may involve the uterosacral ligaments,
rectovaginal space, bowel, ureteral and/or bladder
 deep infiltrating endometriosis occurred without
disease at other sites in only 6.5 percent of patients
 DIE is suspected based on symptomatology (eg,
dysuria, dyschezia, hematochezia) and/or physical
examination (eg, uterosacral ligament tenderness
with dense nodules, non-mobile uterus)
recommendations regarding
conservative and definitive
 ●Conservative surgery is the first-line option
for most women planning surgical treatment
of endometriosis
continue
 suggest hysterectomy rather than
conservative surgery ONLY for women with
persistent bothersome symptoms of
endometriosis who do not plan future
childbearing and who have both failed medical
therapy and at least one conservative
treatment procedure
 Definitive surgery is also reasonable for
women who have additional indications
for hysterectomy
 For women undergoing hysterectomy for treatment of
endometriosis►bilateral salpingooophorectomy ONLY for those who value decreasing
the risk of reoperation more than avoiding the risks of
premature menopause
 preference for oophorectomy ► woman approaches
menopause
 Oophorectomy is also reasonable for women with
extensive disease involving the ovaries.
 the preoperative evaluation should include appropriate
additional testing
 This includes evaluation of the urinary or gastrointestinal
tract
 magnetic resonance imaging (MRI) or rectal sonography
may suggest an obliterated pelvic cul-de-sac
 transvaginal ultrasonography, one can look for the “sliding
sign” when placing the probe in the posterior fornix to see
if the anterior rectal wall glides smoothly over the retrocervix. If there is no such sliding observed, then there is a
high probability of obliteration of the cul-de-sac by
endometriosis
Preoperative medical suppressive
therapy
 Hormonal suppression has been used prior to surgery to
decrease the size of endometriotic implants, thereby
reducing the extent of surgery required
 there is no evidence that preoperative hormonal
intervention decreases the extent of surgical
dissection required to remove implants, prolongs the
duration of pain relief, increases future pregnancy
rates, or decreases recurrence rates
 Use of preoperative GnRH agonists reduced disease seen at
the time of the second surgery, but there was no evidence
that this translated into prolonged duration of pain relief
or a decreased recurrence rate
Antibiotic prophylaxis
 Operative laparoscopy is typically a clean procedure,
and antibiotic prophylaxis is not generally used
 we give prophylactic antibiotics to patients if there is
suspicion of adhesive bowel disease, based upon the
increased risk of bowel injury
Thromboprophylaxis
 Use of mechanical or pharmacologic
prophylaxis depends upon the
procedure and patient risk factors
 Bowel preparation is not routine in
current practice prior to surgery for
endometriosis.
 Ablation versus excision
 The choice of modality is based upon
surgeon experience and preference
 Two randomized trials comparing excision
with ablation (monopolar electrosurgery in
one trial, diathermic ablation in the other)
found no difference in pain scores at 6 to 12
months
 any difference is likely of trivial clinical
significance. There are no high quality data
comparing among the various ablative
modalities (laser, electrosurgery,
ultrasound)
 Adhesiolysis
 adhesive disease; the reported rate is 70 percent in
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women with and without prior surgery
Red lesions are associated with more adhesions than
women with only black, white and/or clear lesions
, surgery to ameliorate the adhesions is not always
effective
we perform adhesiolysis selectively
We resect all adhesions that may compromise fertility or
that correspond to the location of the patient’s pain.
Surgical management of DIE requires specialized skills
to adequately remove extensive disease
The goal is to re-establish normal anatomy
POSTOPERATIVE CARE
 Postoperative medical therapy :
 We recommend postoperative medical suppressive therapy for most
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women treated surgically for endometriosis
hormonal therapy increased the duration of pain relief and delayed
recurrence of disease
postoperative insertion of the levonorgestrel-releasing intrauterine
device (LNG IUD) results in decreased dysmenorrhea compared with
expectant management
first-line therapy is estrogen-progestin contraceptives or oral
progestins alone, both of which are easy to tolerate and cost-effective.
Another option is a LNG IUD
GnRH
Hormonal treatment is typically not necessary following oophorectomy.
Suppression with a progestin is appropriate if symptoms recur after
hysterectomy and oophorectomy
Use of a progestin may be contraindicated in women with risk
factors for breast cancer.
Postmenopausal hormone therapy
after oophorectomy
 Postmenopausal hormone therapy with low-dose
estrogen (equivalent of 0.625 mg conjugated equine
estrogens) is not contraindicated in women following
an oophorectomy for endometriosis.
 Treatment may be initiated immediately after surgery
 the probability of a recurrence in women treated with
estrogen therapy is very low (3.5 percent)
 There is no evidence to support the addition of a
progestin to prevent malignant transformation in
residual endometriosis lesions or to help suppress
growth of such tissue
Repeat surgery
 Pelvic pain symptoms often recur after conservative
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surgical treatment of endometriosis
A patient who presents with recurrent pelvic pain following
surgical treatment should be evaluated to ensure that the
most likely cause is endometriosis
If the patient is not on medical therapy, medical therapy
should be initiated and other modalities may be helpful
(eg, pelvic physical therapy)
Surgery may be the only option if a woman has had
severe adverse effects from hormonal therapy.
For women who have undergone conservative surgery, the
patient should be counseled regarding whether to undergo
further conservative surgery or definitive surgery