Microsoft word - m3endo.doc

ENDOMETRIOSIS
Cyclic pain can become constant over timeNon-responsive to NSAIDs and BCPs Scarred dark lesionsMultiple other appearances Glands, stroma and hemosiderinIndividual componentsFibromuscular metaplasia Cyclic pain can become constant over timeSymptoms may precede diagnosis by 8 years (average).
Non-responsive to NSAIDa and BCPs Increased findings on examination during menses CA-125 can be used for longitudinal observationAnti-endometrial antibodies are experimental.
Ovarian endometrioma – Ground glass appearanceThe cyst persists over time Scarred dark lesionsMultiple other appearancesHistology diagnosis for unusual appearances Low malignant potential tumorMetastatic breast cancer Histologic confirmation is research topic Histologic Criteria for the Diagnosis of Endometriosis (Batt 1989 and 2003) Grade 1: Possible residua of resorbed endometriosis, i.e. hemosiderin, calcium, nerve,blood vessels and smooth muscle.
Grade 2: Consistent with endometriosis, i.e. hemosiderin, characteristic glands, orstroma.
Grade 3: Definite endometriosis, i.e. characteristic glands and stroma withhemosiderin.
Grade 4: Grade III with structures conveying and organoid pattern, i.e. glandular-stromal layer overlying well developed smooth muscle layer.
Batt RE, Smith RA, Buck GM, et al. A case series - peritoneal pockets andendometriosis: rudimentary duplications of the mullerian system. Adolesc PediatrGynecol 2:47, 1989.
Batt R, Mitwally MF. Endometriosis from thelarche to midteens: pathogenesis andprognosis, prevention and pedagogy. J Pediatr Adolesc Gynecol. 16:333-347, 2003 Histologic Criteria for the Diagnosis of Endometriosis (Preliminary Research) Grade 1: Peritoneal vesicles, red polyps, yellow polyps, hypervascularity, scar,adhesions.
Grade 2: Chocolate cyst with free flow of chocolate fluid.
Grade 3: Dark, scarred (or puckered, pigmented) lesions, red lesion on fibrous scarredbackground, chocolate cyst with mottled red and dark areas on white background.
Grade 4: Dark, scarred (or puckered, pigmented) lesions at first surgery.
Martin DC. Applying STARD criteria to the laparoscopic identification ofendometriosis. Fertil Steril 86 (Suppl 2): s269, 2006 (Abstract) INITIAL INFERTILITY EVALUATION
Causes in women include ovulatory disorders such as PCOS, adhesions, tubal blockage,prolactinemia, endometriosis, fibroids, endometrial scar… Failure to conceive after 12 months of adequate, unprotect sex.
Start evaluation at 6 months if there are known medical factors such as PCOS, tubaladhesions, > 35 Years OldFecundability is the probability of conceiving in one month.
7.7 % in first year of trying in healthy couplesEndometriosis with no other factors 6.8 % with 1 to 2 years of infertility4.4 % with 3 to 8 years of infertilityNone with 8 to 13 years of infertility 4.9 % with 1 to 2 years of infertility3.3 % with 3 to 8 years of infertility0.6 % with 8 to 13 years of infertility General healthPrevious pregnanciesMenstrual cycleHirsutismWeight changes Prolactin - breast milk hormoneThyroid - check of the thyroid gland.
6 to 8 Days after ovulationDay 21 to 24 of cycle Positive at ovulationEarly reaction 2 to 4 days before ovulation Billing’s mucus observationSaliva observation for ferningBasal body temperature chart.
Avoid sex for two to five days.
Have the sperm specimen at the lab within one hour.
Hysterosalpingogram (HSG) is an X-ray of the uterine cavity and tubes Hysteroscopy and D&C if the lining is abnormal.
OTHER TESTS
Sonogram (ultrasound) is to check on the thickness of the uterine lining (6mm to 12 mm)and ovulation changes in the ovaries.
Sonohysterogram for cavity contour, polyps, sub-mucus myomataEndometrial Aspiration or Biopsy This is done in the office on day 10-12 after ovulation.
This confirms progesterone changes in the uterine lining.
Post-Coital Test (PCT, Sims Huhner’s Test, mucus - sperm check) This is scheduled near ovulation. This is like a Pap smearThe test is 6 to 18 hours after sex. .
Estradiol – Ovarian hormone that prepares mucus and lining.
LH/FSH - brain hormone that controls ovaries and testes.
DHEAS – male-like hormone from the adrenal gland.
Androstenedione – male-like hormone from the ovary.
Free Testosterone - male hormone from the adrenal gland or ovary.
Day 3 FSH and E2 to check ovarian reserves - works best over 40Clomid challenge test to check ovarian reserves - works best over 40.
Blood type and Rh, hepatitis, syphilis, HIVRubella (German measles) titer to determine immunity.
T-mycoplasma or ureaplasma may be associated with miscarriages.
Lupus anticoagulant may be associated with miscarriages.
Anticardiolipid antibodies may be associated with miscarriages.
Chromosome analysis to check for inherited problems.
Chlamydia immunoglobulin for old or deep infection.
Blood or body chemistry levels to check for overall health.
TREATMENT
Menopausal gonadotropinsHCGDostinex / ParlodelThyroid / Tapazole ObservationMedication – BCPs, Lupron, Danazol, AISurgery Observation at less than 3 cm and no cavity distortionSurgery

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