Gynaecology Thrissur

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Articles for the practicing clinician.

 Fibroids

Ovarian cysts 

Vaginal discharge

Endometriosis  

Dysfunctional uterine bleeding 

Infertility  

Anovulation   Contraception   Menopause   Chronic pelvic pain 
    

Endometriosis may be defined as the presence of functioning endometrial tissue outside the uterus. It is usually confined to the pelvis in the region of the ovaries, uterosacral ligaments, cul-de-sac, and uterovesical peritoneum. The development and extension of endometrial tissue into the myometrium is termed adenomyosis. An endometrioma may be defined as an area of endometriosis, usually in the ovary, that has enlarged sufficiently to be classified as a tumor. When an endometrioma is filled with old blood, resembling tar or chocolate syrup, it is commonly known as a chocolate cyst.

 

Clinical features & diagnosis of Endometriosis: Endometriosis classically presents with pelvic pain,dyspareunia,congestive dysmenorrhoea or as infertility.  Pain,is usually bilateral, varies from mild to severe discomfort in the lower abdomen and is often associated with rectal pressure. Many affected women complain of lower back and leg pain. A constant soreness in the lower abdomen or pelvis throughout the cycle, which is aggravated just before the menses or during coitus, may be the only complaint. Since many of these symptoms mimic many other illnesses, diagnosing endometriosis can be difficult. Endometriosis can manifest as nodularity in the pouch of Douglas, decreased mobility of uterus due to pelvic adhesions, masses in the pelvis due to ovarian endometriosis,etc.  The best time to examine a patient with suspected endometriosis is postmenstrually. At this time the nodularities found on pelvic examination increase in size, confirming the suspicion of endometriosis.

.Besides the usual sites like ovaries, uterosacral ligaments, cul-de-sac and uterovesical peritoneum, endometriosis can present at unusual sites like lungs, liver, rectovaginal septum, scar tissue, etc. These implants could present as haemoptyis (lungs), cyclic right subcostal pain (liver), painful defaecation or bleeding per rectum during periods (rectovaginal septum), or as pain with defaecation and malena(Colon).

For confirmatory diagnosis,currently, the "gold standard"  is direct visualization of endometrial lesions using laparoscopy, often with confirmation by biopsy of excised endometriotic tissue.(8).Ultrasound scanning ,a diagnostic modality used widely for the detection of a wide arrayof pathologies is not very much useful in confirming the diagnosis of endometriosis.  Ovarian endometriomas can be detected on ultrasound scanning, but external endometriotic implants, for example,the ones on uterosacrals and pelvic peritoneum  cannot be picked up on sonography. Presumptive diagnosis of adhesions can be made from the fixity of ovaries, and uterus on ultrasound, but a definitive diagnosis requires a laparoscope. CT scanning and MRI may be useful in diagnosing endometriosis at extrapelvic sites of endometriosis like lungs and liver, but are not of much use in pelvic endometriosis. 

 

Medical treatment  of endometriosis: The medical therapy of endometriosis is done with agents like OC-pills, progestins,NSAID’s,Danazol and GnRh analogues.  The objective is to produce a state of amenorrhoea which may be akin to a pseudopregnancy(OC-Pills,progestins) or pseudomenopause(Danazol,GnRh analogues). This inhibits or delays progression of the disease.

OC-pills: Initial management in a patient suspected of having endometriosis and not desiring pregnancy is to start on OC-pills and NSAID’s for 3 months.  If there is no response,  there is no point in switching over to another brand of OC-pills or NSAID. A more aggressive approach is needed.

Progestins: Oral administration of medroxyprogesterone acetate, 50 mg daily,can  improve symptoms in 80% of patients with moderate to severe endometriosis. Minor bleeding, weight gain and edema, are some of the side effects that are usually  well tolerated. Subjective improvement in symptoms has been noted by some workers with 30 mg of medroxyprogesterone acetate. Unfortunately, recurrence rates have been reported to reach 42% after 2 years of therapy. As an alternative to medroxyprogesterone acetate, one may choose to administer norethindrone acetate, 5 mg daily for 6 months. A similar response can also be achieved with 40 mg of megestrol acetate daily. Parenteral medroxyprogesterone acetate depot may also be given at a dose of 100 mg every 2 weeks for 3 months followed by 200 mg monthly for 3 to 6 months.

Danazol: Danazol is a weakly androgenic preparation. In doses of 200mg/day it can reduce  pelvic pain but for effectively reducing endometriosis doses that can produce amenorrhoea is required. 400-800mg/day may be needed to produce amenorrhoea.  Danazol is teratogenic and patients at risk of getting pregnant should be asked to use contraception. It may be given for 8-12 weeks preoperatively before repeat surgery. For patients who refuse surgery, 52-78weeks course may be necessary. More than 75% of patients receiving danazol have one or more side effects. Major side effects seen with danazol therapy are  weight gain, edema, decreased breast size, acne, oily skin, hirsutism,deepening of the voice, headache, hot flashes, changes in libido, and muscle cramps.Significant weight gain (2 to 10 kg) is not uncommon. All these side effects are reversible with the exception of voice changes. The time course for the resolution of androgenic symptoms may be long; 6 months or more is usual.

Gonadotropin-Releasing Hormone Agonist Therapy: GnRH is a hypothalamic decapeptide that stimulates pituitary LH and FSH secretion. Chemicals similar in structure to the native gonadotropin releasing hormone is used to induce amenorrhoea. Depot preparations of these compounds are usually used to produce amenorrhoea. The effects are comparable to Danazol without the androgenic side effects of Danazol.  Dose: Goserlin and leuprolide are 2 depot preparations available in India. The dosage of leuprolide is a single monthly 3.75-mg depot injection given intramuscularly every month. Gosarelin, in a dosage of 3.6 mg, is administered subcutaneously every 28 days. Treatment should be continued for at least 3months. Each injection may cost upto Rs.7000-8000. There may be estrogenic side effects like dry vagina, hot flashes,etc. These can be prevented by giving estrogens and progestogens .For e.g:Conjugated estrogens in the dose of 1.25mg with Medroxyprogesterone acetate 2.5 mg daily.

 

Surgical treatment of endometriosis:

Laparoscopic adhesiolysis, and fulgration of implants form the main stay of surgical treatment.  Endometriomas are drained and the cyst lining  either peeled off   or fulgrated using cautery or laser.In women who have completed their family hysterectomy with salpingo-oophorectomy  is the definitive mode of therapy.

 

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