endometriosis oxford

Conceptual and diagnostic Endometriosis Problems : 

The definition ‘endometrial glands and stroma ……..’ 1 or 3-4 diseases ? are subtle lesions a disease ? are ( most ) typical , cystic and deep endometriotic lesions end stages without progression from one to another adenomyosis , peritoneal pockets , müllerianosis a normal tissue or a benign tumour ? Conceptual and diagnostic Endometriosis Problems ESGE->Leuven Barcelona 2010 Philippe Koninckx

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Endometriosis defined as Glands and stroma outside the uterine cavity Subtle lesions Cystic Ovarian” Typical Lesions Adenomyosis Deep “ Adenomyosis externa ”

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Endometriosis defined as Glands and stroma outside the uterine cavity Superficial lesions Subtle Typical

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Endometriosis defined as Glands and stroma outside the uterine cavity Cystic Ovarian

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Endometriosis defined as Glands and stroma outside the uterine cavity Deep

Symptoms vary with lesion: 

Symptoms vary with lesion Prevalence Pain Infertility Subtle : 80% no no Typical : 25% in 50% + ? Cystic : 10% in 80% +++ ++++ Deep : 2-3% in 95% ++++ ??? Adenomyosis Peritoneal pockets – Müllerianosis - Choristoma

Conceptual problems & Confusion: 

Conceptual problems & Confusion If Subtle is considered a disease >80 % of women have endometriosis Although no evidence that it causes infertility or pain evidence that subtle is not associated with LUF Inclusion in trials inclusion in pain trials will kill any product Diagnosis means eradication The elephant in the room = desinformation type of endometriosis lesions are rarely stated « endometriosis» is used to create confusion

Conceptual problems & Confusion: 

Conceptual problems & Confusion Typical lesions Infertility : Associated with LUF syndrome Only argument for association with infertility Marcoux trial is not an argument Pain : associated with moderate pain in 50% Thus no pain in 50% Consider problem for any medical treatment trial When diagnosed = gone Thus those included with ‘proven typical endometriosis’ have pain for other reasons than endometriosis

Conceptual problems & Confusion: 

Conceptual problems & Confusion Cystic ovarian endometriosis Clearly associated with adhesions, Infertility & rather severe pain Although not in all : 80% Clinical problems Diagnosis : ultrasound 85% sensit and 85% specificity Unnecessary surgery for corpus luteum Avoidable surgical ovarian damage = ovarian reserve Association with ovarian cancer is debatable

Conceptual problems & Confusion: 

Conceptual problems & Confusion Deep Endometriosis Clearly associated with very severe pain in 95% Definition s = deeper than 5% (includes typical) = adenomyosis externa Clinical problems Demanding surgery including ureters and bowels Expertise required to make the diagnosis No exam is really conclusive Even during surgery : easily missed

Expertise required : 

Expertise required pain ++ perineal Radiation All exams Negative Clinical , MRI, contrast enema hysterectomy

Deep endometriosis: 

Deep endometriosis Thank you For listening

Conceptual and diagnostic Endometriosis Problems : 

The definition ‘endometrial glands and stroma ……..’ 1 or 3-4 diseases ? are subtle lesions a disease ? are ( most ) typical , cystic and deep endometriotic lesions end stages without progression from one to another adenomyosis , peritoneal pockets , müllerianosis a normal tissue or a benign tumour ? Conceptual and diagnostic Endometriosis Problems ESGE->Leuven Barcelona 2010 Philippe Koninckx

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Pathophysiology : Theories Sampson Speculated 100 years ago And we believed it since .... Viable cells in menstruation Retrograde menstruation Viable cells in PF Implantation potential Keebiel WC, Stein RJ. Am J Obstet Gynecol 1951; 61:440-442. Koninckx PR et al. J.Reprod.Med. 1980; 24:257-260 . but in >90% of women In humans, in primates, in nude mice, in vitro Metaplasia Is essentially the same Why progression in some women only ? Endometriosis is a genetic disease Hereditary Deep and cystic are clonal in origin Total body radiation, Dioxin Endometriotic Disease Theory

The Endometriotic Disease Theory: 

The Endometriotic Disease Theory Genetic mutation cause a cell to become tumorous Koninckx P.R., Kennedy S., Barlow D., Gyn Obstet Invest 1999,47,1-10

The Endometriotic Disease Theory: 

Implantation Metaplasia Progression Endometriotic disease Endometriosis Deep Cystic Ovarian Adhesions Typical Subtle lesions Retrograde menstruation, Remodeling, Genetic mutation favorised by heredity immunology volume environment Sampson - Metaplasia The Endometriotic Disease Theory Koninckx P.R., Kennedy S., Barlow D., Gyn Obstet Invest 1999,47,1-10

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A benign tumour Clinical importance Sampson/Metaplasia Implantation is key Subtle ++ Why Progression ?? A normal cell Endometriotic Disease Theory In an abnormal environment Implantation occurs in all women Subtle is a normal condition Genomic incident ->Progression Explains heredity, dioxin, irradiation … predisposition … clonality … big deep lesions as soon as 1 year after menarche An abnormal cell

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Macroscopically : several types of endometriosis Subtle Typical Cystic Ovarian Endometriosis Deep endometriosis Adenomyosis Peritoneal pockets Stromatosis endosalpingiose Conclusion : several or 1 pathology ? Microscopically active burnth-out ……. adenomyosis Adenomyosis No glands

Deep endometriosis: 

Deep endometriosis Adenomyotic nodule Generally unique Generally > 1 cm Mutiple localisations Growing ?? End stage Infiltrating : specific Yes : muscular - neural - vagina No : ureter fat Metastatic : Suggesting that this is not always a proliferative disease

3 diseases not 1 disease : 

3 diseases not 1 disease There is no such thing like endometriosis ; there are typical, cystic and deep lesions If you believe Sampsom : 1 disease Retrograde menstruation and progression Recurrent and progressive disease – alibi for incomplete surgery Symptoms cannot be defined eg pain from 0 till +++ Prevalence of 80% since subtle is considered endometriosis Endometriotic disease theory = mutation (Koninckx et al 1999) Subtle is not a pathology Typical, cystic and deep are end stages Rarely progressive and not recurrent Symptoms are easy to describe

A progressive and recurrent disease ?: 

A progressive and recurrent disease ? Progressive ? Typical and cystic is inactive disease Only subtle is active : concept of remodeling Deep is active in the deeper part , but all nodules followed, do not grow Recurrent ? Deep 1% Cystic 5% Typical 20% ??

Management : Pain : 

Management : Pain Clinical evaluation and decision to make a laparoscopy or to wait Eventually short term diagnostic medical treatment Additional exams Ultrasound MRI ? If decision for surgery is taken Additional exams ? Who ? Preferentially one step surgery Thus delay in diagnosis does not exist

Etiology of chronic pelvic pain: 

Etiology of chronic pelvic pain Pelvic pathology Deep Endometriosis Adhesions Ovarian cysts…… Oviduct : hydrosalpinx, eup Uterus : adenomyosis , myoma Pelvic floor and retroversion Pelvic congestion Chronic PID Chronic EUG Intestinal pathology Colon, appendix, small bowel Functional and organical Interstitial cystitis Referred pain from sacro ileac joint Nerve entrapment in the wall You only recognise what you know You only find what you are looking for clinical exam laparoscopy cystoscopy imaging…….

Management : infertility : 

Management : infertility If also pain : indication for laparoscopy But few fertility specialist can deal with occasion severe endometriosis No pain : unclear Systematic laparoscopy Culdoscopy ?

Conclusions : 

Conclusions At least 3 diseases Confusion in the literature Difficulty to do pain trials Placebo effect Subtle is not a disease