Endometriosis

Beningna gynecological disorders in women’s health is very disturbing where the glands and stroma resembling endometrium (“endometrium like”) were also found outside the uterus. The psychological impact of severe pain that occurs is increasing due to the impact of this disease on fertility patients.

The disease is never complete recovery and therapy aimed at suppression of lesions in medical (medical suppression) – excision (surgical excision) and relieve the patient complaint.

EVENT NUMBERS

• In the general population Endometriosis occurs in 7-10% of women.

• Because this is a disease that “estrogen dependent” then the disease only occurs in women during reproductive age.

• The prevalence of endometriosis in infertility patients approximately 20-50% (Rawson, 1991; Strathy, 1982; Verkauf, 1987).

• Prevalence in patients with chronic pelvic pain approximately 80% (Carter, 1994).

• Evidence of endometriosis during laparoscopy on asymptomatic women approximately 20-50% (Williams, 1997).

• There is a factor of family relationships in which the incidence of endometriosis 10 times greater in first degree family relationships (Cramer, 1987).

• monozygotic twins is associated with endometriosis (Hadfield, 1997).

Etiology and Pathogenesis

• Menstruation, retrograde

• Spread of lymphatic and hematogenik

• metaplasia Coelomic

• immuno-genetic defect

• Environmental (pesticides, plastic bag)

• Anatomical Distribution

PATHOLOGY

Location endometriosis:

1. Ovary

2. Cavum Douglassi

3. Ligament sacrouterina

4. Ligamentum latum

5. Fallopian tubes

6. Plica vesicouterina

7. Ligamentum rotundum

8. Appendix vermoformis

9. Vagina

10. Septum rectovagina

11. Colon rectosigmoid

12. Caecum

13. Ileum

14. Inguinal canal

15. Abdominal scar tissue

16. Ureter

17. Gallbladder urinaria

18. Umbilicus

19. Vulva

20. Faraway places

Wherever the location of endometriosis, there is an ectopic endometrial stromal sheathed experiencing implantation and shaped like a miniature cysts and cyclic response to estrogen and progesterone as well as the endometrium in the cavum uteri. During the process of menstruation, bleeding on the mini cysts.

Blood – The network of endometrial tissue and fluid will be trapped in the cyst.

In the next cycle, tissue fluid and blood plasma absorbed and leaves a thick black-colored blood. The cycle repeated every month and gradually become a large cyst containing brown liquid that more and more.

The maximum size of the cyst depends on the location. Small cyst will remain small and occur serbukan fibriotik lesion macrophages to become small.

Ovarian cysts (endometriomas) tend to increase in size to the size of an orange. With the enlargement of cysts, cyst cell damage that it becomes non-functional.

Rupture or leakage of small cysts often occur that cause the attachment of the surrounding tissues. Then, endometriosis occurring in the ligamentum latum primary or secondary, occurs through the spread of the ovary.

Lesions in the cavum Douglassi often not visible unless you inspection is done at the time of menstruation.

CLINICAL

Clinical features are often specific. 25% of cases of patients with endometriosis have no symptoms; the remainder showed symptoms vary greatly depending on location and not on the extent of disease.

Symptoms that may occur:

• Pain

• Menstrual Disorders

• Dyspareunia

• Dysuria

• Dyschezia

• Infertility

Pain

Lower abdominal spasms that began prior to menstruation and peaked a few days of menstruation and gradually subsided.

Pain is referred to as DYSMENORRHOEA.

When the endometrial cyst is quite large, and accompanied by attachment or lesions involving the peritoneum around the bowel complaint aka tone lower abdominal pain that settled outside the menstrual cycle and with varying intensity.

Menstruation disorders

In 60% of patients with endometriosis, menstrual cycle disruption.

Complaints may be pre-menstrual spotting (spotting), menorrhagia or menstrual period is short.

Dyspareunia

When the endometrium was in cavum douglassi, especially when accompanied by retro-versio uteri and attachment, there will be complaints dyspareunia during penile penetration run optimally when sexual intercourse.

When the lesion involves the peritoneal colon then there will be pain when defikasi.

Infertility

Endometriosis is often accompanied by infertility, this may be related to the distortion of the internal reproductive tract.

Sometimes the diagnosis of endometriosis is detected only after an examination of infertility using laparoscopy.

CLINICAL EXAMINATION

• abdominal examination and biamual unable to find any small lesions. It is recommended to perform bimanual examination during or just after menstruation in order to find lesions in the cavum douglassi commonly enlarged during menstruation.

• large cysts that are often found embedded easily on bimanual examination.

MANAGEMENT

Depending on:

• The extent of disease as laparoscopic ditemukans AAT.

• The function of reproduction.

1. OBSERVATIONS

In patients asymptomatic or with mild pain.

In infertile patients with mild abnormalities ekspektatif therapy should be performed.

2. Analgesic Therapy

a. NSAID’s

b. Prostaglandine synthetase – inhibiting drugs

3. HORMONAL THERAPY

a. Oral contraceptive pill

1. Especially the type of monophasic

2. Given daily for 6-12 months

3. If there is bleeding lucut provide additional estrogen

b. Progestin

• Working with mechanisms such as oral contraceptives

• Medroxyprogesterone acetate-MPA dose 10-30 mg / day

• Alternatives: Depo-Provera 150 mg every 3 months

c. Danazol

- Danazol is a weak androgen which is a derivate of isoxazole 17α – ethinyl testosterone (ethisterone)

- Mechanism of action of drugs:

1. Danazol works at the level of the hypothalamus to prevent the release of gonadotropins, thereby preventing the release of FSH and LH.

2. Danazol prevent enzyme activity in ovarian steroidogenesis resulting in an atmosphere that adds hipoestrogenik androgenic effects of Danazole to prevent the growth of the endometrium.

a. Dose of 800 mg / day qid for 6 months

b. The pain can be overcome with the use of Danazol in 90% of cases.

c. Side effects:

1. Pimple

2. Increased weight

3. Edema

4. Changes in plasma lipoprotein

5. Changes in sound (sometimes permanent)

d. Gestrinone

1. Gestrinone is from 19-nortestosterone derivate that acts to suppress FSH and LH

2. Nothing on the market USA

3. Effective but androgenic side effects are prominent and there is no resistance at ovulation.

e. GnRH agonist

1. Analogous to the 10-aminoacid peptide hormone GnRH

2. Gonadotropin secretion by suppression occurs due to eliminate and suppress endometrial ovarian steroidogenesis.

3. The pain disappeared in the second or the third

4. Provision of GnRH agonists:

1.1. Leuprolide 3.75 mg / month by intramuscular

1.2. Nafareline 200 mg 2 times daily intranasal

1.3. Goserelin 3.75 mg / month subcutan.

5. GnRH agonists should only be given for 6 months because of side effects such hipoestrogenik status with the consequent further reduction in bone density.

6. Other side effects: vasomotor symptoms, dry mouth and a sense of emotional disturbance

7. Research shows that when the added provision of norethindrone 2.5 mg or 0625 mg conjugated estrogen + MPA 5 mg per day, seems to side effects of vasomotor symptoms and a decrease in bone density is reduced.

8. To avoid a decrease in bone density seems sufficient if given norethindrone acetate 5 mg alone or accompanied also by giving low dose CE.

4. SURGICAL THERAPY

• Treatment of conservative surgery performed on:

o Case infertility

o severe disease with severe adhesions

o Age “old”

• conservative surgical therapy include the release of adhesions, endometriotic tissue damage, anatomical reconstruction as possible.

• When no longer needed reproductive function: TAH + BSO and lysis of all adhesions that occur.

COMPARISON BETWEEN MEDICAL AND SURGICAL INTERVENTION:

Advantages of medical interventions:

1. Lower cost

2. Empirical therapy (can be easily modified)

3. Effective for pain relief

Loss of medical interventions:

1. Common side effects

2. Does not improve fertility

3. Some drugs can only be used for a short time

Advantages surgical intervention:

1. Effective for pain relief

2. More efficient than medical therapy

3. Biopsy can be enforced through definite diagnosis

Losses surgical intervention:

1. Cost

2. Medical risk “poorly defined … and probably underestimated” about 3%

3. Efficiency of doubt, temporary pain relieving effect of 70-80%.

Ilustration of endometriosis location taken from http://lh3.ggpht.com/_ezSsIEHCzdA/Ss8kj7u8iaI/AAAAAAAAAxE/bEvv9Xdi6R8/s1600-h/S01790026f0013.jpg