rh06 chang endometriosis
DESCRIPTION
Penjelasan endometriosisTRANSCRIPT
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Endometriosis
R. Jeffrey Chang, M.D.Department of Reproductive Medicine
UCSD School of MedicineLa Jolla, California
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Commercial Disclosures (9.9.06)
Entity Activity
Wyeth Research fundingSerono Research supportTakeda Research supportBerlex Research support
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Learning Objectives
• Identify the symptoms and consequences associated with endometriosis
• Describe various treatment options in the management of endometriosis
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Definition
• Endometriosis is a disease in which endometrial glands and stroma implant and grow in areas outside the uterus
• Most commonly implants are found in the pelvis
• Lesions may occur at distant sites: pleural cavity, liver, kidney, gluteal muscles, bladder, etc
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Features of Endometriosis
• Prevalence 2-50% of women; 21-47% of infertility cases
• Exposure to ovarian hormones appears to be essential
• No known racial or socioeconomic predilection
• Severe disease may occur in families
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Is Endometriosis Increasing?
• 1965-1984, endometriosis rose from 10 to 19% as
primary indication for hysterectomy
• Simultaneously, a trend of more conservative therapies
was occurring, which suggests a true increase in the
incidence
• Theories include delay of childbearing, less use of OCs,
and exposure to environmental toxins such as dioxin
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Etiologies of Endometriosis• Sampson's theory: Retrograde menses and peritoneal
implantation– Most women retrograde menstruate
• Meyer's theory: Coelomic metaplasia– Low incidence of pleural disease
• Halban's theory: Hematogenous or lymphatic spread to distant tissues – Does not explain gravity dependent disease sites
• Immunogenic defect
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Normal Pelvic Structures
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Endometriosis
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Endometriosis
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Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis
4* 9
11429
* Revised AFS Score
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Clinical Presentation
• Pelvic pain
• Infertility
• Pelvic mass
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Pelvic Pain
• Frequency – Cyclic: Variable length prior to and after
menses – Acyclic: constant and unrelenting
• Associated activities– May include dyspareunia, dysuria, or
dyschezia
• Other sites of pain– Muscle regions– Distant tissues
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Infertility
• Moderate to severe disease
– Adhesions
– Distortion of normal anatomy
– Prevent sperm-egg interaction
• Minimal to mild disease
– Mild infertility
– Mechanism(s) unknown
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Physical Findings
• Tender nodules along the uterosacral ligaments or in the cul-de-sac, especially just before menses
• Pain or induration without nodules commonly in the cul-de-sac or rectovaginal septum
• Uterine or adnexal fixation, or an adnexal mass
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Diagnosis of Endometriosis
• Direct visualization of implants– Laparoscopically– Conscious pain mapping
• Imaging of endometriomas– MR appears to be best (3 mm implants)– Ultrasound helpful in office setting
• Biochemical markers – Lack specificity
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Endometriosis
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Endometriosis
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MR of Endometrioma
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Endometrioma
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Treatment of Endometriosis
• Management of pain– Surgery – Medical therapy
• Treatment of infertility– Surgery– Ovulation induction– Assisted reproductive technology
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Management of Pain
• Surgical treatment
– Ablation of endometrial implants
– Lysis of adhesions
– Ablation of uterosacral nerves
– Resection of endometriomas
• Combined surgical and medical treatment
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Endometriosis
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Removal of Endometriosis
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Dissection of an Endometrioma
Tube
OvaryIncision
Removal Result
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Treatment of Pain
• Medical management (ovarian suppression, removal of
estrogen)
– Oral contraceptives, progestin, danazol
– GnRH agonist with add-back
– Alternating GnRH agonist and OCs
– Aromatase inhibitors
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Medical Treatment
Ovary Estrogen
EndometriosisTissue
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Medical Treatment
Ovary Estrogen
EndometriosisTissueOral contraceptives
DanazolGnRH agonists
Progestin
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Role of Estrogen in Endometriosis
Estrogen
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Role of Estrogen in Endometriosis
Estrogen
Cell growth
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Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
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Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
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Aromatase In Endometriosis• Aromatase is key for the biosynthesis of
estrogen
• In patients aromatase expression is higher in endometriosis tissue than in normal endometrium
• In endometriosis tissue aromatase activity is stimulated by prostaglandin
• Estrogen synthesized by endometriotic tissue stimulates growth of lesions
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Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
Aromatase Inhibitors • Letrozole
• Exemestane • Anastrozole
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Role of Estrogen in Endometriosis
Aromatase
Estrogen
Cell growth
PGE2Cytokines
Aromatase Inhibitors • Letrozole
• Exemestane • Anastrozole• Danazol
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Treatment of Infertility• Removal of disease
– Surgery improve conception rates at all stages
• Ovulation induction– Gonadotropins with ovarian suppression – Insemination with either clomiphene or FSH
• Medical suppression of ovarian function– No benefit
• Assisted reproductive technology