Endometriosis

 

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Best Treatment Specialist for Endometrosis

ODISHA CENTRE FOR L.I.F.E

(LAPAROSCOPY, INFERTILITY, FIBROIDS & ENDOMETRIOSIS)

  • 1 in 10 Women experience endometriosis in their reproductive years between ages (15 and 49)
  • 20-25 % of women with endometriosis have no symptoms.
  • 30-35 % of women with endometriosis are infertile.
  • 7.5 years the average it takes from the onset of symptoms until proper diagnosis.
  • It is a condition that occurs when tissue similar to the inside lining of the uterus is found outside of its normal location. Endometrial implants can be found on the ovaries, fallopian tubes, and ligaments that support the uterus and tissue covering the bladder and rectum. The most common locations of endometrial implants in teens are in the cul–de–sac area (behind the uterus), and near the bladder.

     

     

    What causes endometriosis?

    The exact cause is not known. It is thought that some cells from the womb (uterus) lining (the endometrium) get outside the uterus through the tubes by retrograde flow into the pelvic area. The ‘spilt’ endometrial cells then continue to survive next to the uterus, ovary, bladder, bowel, or Fallopian tube or even on previous scars like that of caesarean section. The cells respond to the female hormone oestrogen, just like the lining of the uterus does each month. Throughout each month the cells multiply and swell, and then break down as if ready to be shed at the time of your period. However, because they are trapped inside the pelvic area, they cannot escape. They form patches of tissue called endometriosis. Patches of endometriosis tend to be adhesion forming and may hence join organs to each otherlike bowel to the uterus, omentum to the uterus, ovaries and uterus etc.The cysts can fill with dark blood; this is known as ‘chocolate cysts’.

    With each menstrual cycle, the implants go through the same growing, breaking down, and bleeding that the uterine lining (endometrium) goes through. This is why endometriosis pain may start as mild discomfort a few days before the menstrual period and then usually is gone by the time the period ends. But if an implant grows in a sensitive area, it can cause constant pain or pain during certain activities, such as sex, exercise, or bowel movements.

    Between 20% and 40% of women who are infertile have endometriosis.

    Pain is the main symptom of endometriosis. You may have:

    • Painful periods
    • Pain prior to and after menses
    • Pain during or following sexual intercourse
    • Pain with bowel movements
    • Transvaginal ultrasound
    • Pelvic laparoscopy
     

     

    WHAT ARE THE MAIN SYMPTOMS OF ENDOMETRIOSIS?

    • Painful periods
    • Pain prior to and after menses:dysmenorrhoea
    • Pain during or following sexual intercourse:dyspareunia
    • Pain with bowel movements:dyschezia
    • Pain during micturition: dysuria
    • Bleeding during urination:haematuria
    • Infertility (the inability to become pregnant) or subfertility (a reduced ability to become pregnant)
    • Pelvic pain: in women with endometriosis depends partly on where endometrial implants of endometriosis are located.
    • Deeper implants and implants in areas of high nerve density are more apt to produce pain.
    • The implants may also release substances into the bloodstream, which are capable of eliciting pain.
    • Pain can result when endometriotic implants incite scarring of surrounding tissues. There appears to be no relationship between severity of pain and the amount of anatomical disease which is present.
     

     

    HOW TO DIAGNOSE ENDOMETRIOSIS?

    • Transvaginal ultrasound:An ultrasound may not be able to detect subtle changes due to endometriosis but can help to diagnose an endometrioma/chocolate cyst of any size.A transvaginal ultrasound can detect whether every organ in the pelvis has become adherent to each other( VISCERAL SLIDING SIGN).It can also detect rectovaginal nodule and the size of the nodule in the vagina, how much of the rectum is involved, only if the sonologist doing the scan is skilled enough.

    • MRI: MRI is the second-line imaging technique after USG. Deep pelvic endometriosis causes chronic pelvic pain and infertility. MRI is one the best imaging technique for preoperative staging of endometriosis.



    • Pelvic laparoscopy: The only definitive way to diagnose endometriosis is by a laparoscopy – an operation in which a camera (a laparoscope) is inserted into the pelvis via a small cut near the navel. The surgeon uses the camera to see the pelvic organs and look for any signs of endometriosis.

     

     

    • WHAT IS A CHOCOLATE CYST?

    A chocolate cyst is a type of ovarian cyst filled with old altered blood. These cysts, which gynaecologists call endometriomas, are not usually cancerous, though they usually mean that a person’s endometriosis is severe enough to complicate their fertility. Between 20 and 40 percent of people with endometriosis develop chocolate cysts. They get their name from their brown, tar-like appearance, looking something like melted chocolate. They’re also called ovarian endometriomas.

    The colour comes from old menstrual blood and tissue that fills the cavity of the cyst. A chocolate cyst can affect one or both ovaries, and may occur in multiples or singularly.When occurs in both the ovaries, they often get adherent to the posterior surface of the uterus and close to each other called as KISSING OVARIES.

    Shows how laparoscopy is done



    Large chocolate cyst



    Unilateral chocolate cyst/endometrioma



    Chocolate material being drained out from ovarian cyst

     

     

    WHAT IS THE MEDICAL TREATMENT?

    • ORAL CONTRACEPTIVE PILLS
    • LIFESTYLE MODIFICATION
    • ANTIFIBRINOLYTIC AGENTS
    • GNRH AGONISTS
    • DIENOGEST

    All the above drugs have been tried with no permanent cure. They have various side effects like stoppage of menses for the period for which they are given, flushes, bone pain, weight gain, only temporarily relief and irregular bleeding pv.It is just like delaying the inevitable. The current opinion is that definitive treatment is only by surgery and that too by a skilled surgeon who has experience, enough cases of endometriosis under his belt and has a sound knowledge of the disease. It is often said that the first surgeon doing the surgery has the best chance of removing the whole disease. Subsequent or re do surgeries become more difficult and challenging.

    That is the only reason why we have come with the concept of the ODISHA CENTRE FOR L.I.F.E ( LAPAROSCOPY, INFERTILITY, FIBROIDS AND ENDOMETRIOSIS) to provide a one stop solution to all our patients in the best and complete way possible. The purpose is to treat with methods and drugs at par with international standards, minimise symptoms, optimise fertility, and prevent recurrence. The surgery is done by DR G S S MOHAPATRA, trained at numerous places like France , Germany, Italy for laparoscopy in endometriosis and the technology used in the form of camera system and the gadgets and instruments used are the most advanced and world class.

     

     

    DOES ENDOMETRIOSIS RECUR?

    The most recent studies have shown that endometriosis recurs at a rate of 20% to 40% within five years following conservative surgery, . The use of oral contraceptive, other suppressive hormonal therapy, or progesterone intra uterine device (IUD) after surgery has been shown to reduce the recurrence of pain symptoms but does not remove the disease. Hence the wise option is to go for surgery with a motive to all diseased tissue as much as possible to alleviate symptoms, remove disease and prevent recurrence.

     

     

    DOES SURGERY ENHANCE FERTILTIY?

    With more advanced endometriosis (Stages 3 or 4), surgery can help restore your normal pelvic anatomy to allow the ovaries and fallopian tubes to work better. Surgery to remove large endometriomas may also improve fertility rates. There have been many studies in this regard with a few suggesting surgery helps while others have suggested just the opposite. In our experience, FERTILITY ENHANCING SURGERIES play a pivotal role in early stages of endometriosis with infertility and in the later part an adhesiolysis helps in egg retrieval during the procedure of IVF.

     

     

    WHAT IS DEEP INFILTRATING ENDOMETRIOSIS ( DIE)?

    Deep infiltrating endometriosis (DIE) is a particular form of endometriosis that penetrates >5 mm under the peritoneal surface (Koninckx and Martin, 1994). These lesions are considered very active and are strongly associated with severe pelvic pain.It is stage III or stage IV of endometriosis .It involves organs within the pelvic cavity and can plaster the ovaries, rectum, uterusto each other and can even lead to a drastic condition called as FROZEN PELVIS.

    • Specific MRI or TVUS protocols are highly accurate in making a nonsurgical diagnosis of deep infiltrating endometriosis (DIE).
    • The combination of compelling clinical signs and symptoms and absence of imaging findings for DIE can be used to make a presumptive nonsurgical diagnosis of endometriosis.
    • Empiric medical therapy may provide pain relief.
    • Conservative treatment, including observation alone, may be considered in asymptomatic patients with DIE and in those with minimal pain.
    • Before surgery, it is imperative to know lesion size, depth, circumferential bowel involvement, and location to optimize surgical outcomes.

     

     

    CYSTECTOMY FOR CHOCOLATE CYST/ENDOMETRIOMA

    Endometrioma is one of the most frequent adnexal masses in the premenopausal population, but the recommended treatment is still a subject of debate. Medical therapy is inefficient and can not be recommended in the management of ovarian endometriomas. The general consensus is that ovarian endometriomas larger than 4 cm should be removed, both to reduce pain and to improve spontaneous conception rates. The removal of ovarian endometriomas can be difficult, as the capsule is often densely adherent. While the surgical treatment of choice is surgical laparoscopy, for conservative treatment, the preferred method is cystectomy. We only remove the cyst wall and leave behind the ovary. Hence the ovarian function is preserved. The procedure is done in young unmarried females, in women who are desirous of fertility, who are young, preferably below the age of forty.

    A skilled surgeon who understands the needs of the patient is a must because the AMH ( indicator of ovarian reserve) should not be going down drastically after the surgery. The surgeon should be conservative towards fertility and radical towards the disease.

     

     

    WHAT IS ADENOMYOSIS: THE POOR COUSIN OF ENDOMETRIOSIS

    Adenomyosis is a condition in which the inner lining of the uterus (the endometrium) is found in the muscle wall of the uterus (the myometrium). Adenomyosis can cause menstrual cramps, lower abdominal pressure, and bloating before menstrual periods and can result in heavy periods.

     

     

    TREATMENT OF ADENOMYOSIS:

    • 1. IN YOUNG FEMALES: adenomyomectomy , where the adenomyotic tissue is removed and the uterus is preserved to relieve the patient of her symptoms. It gives wonderful results when done laparoscopically too. https://www.youtube.com/watch?v=OcjAk6MrHB4 : laparoscopic adenomyomectomy by DR G S S MOHAPATRA
    • 2. IN OLDER FEMALES: The only definitive cure for adenomyosis is a hysterectomy, or the removal of the uterus. This is often the treatment of choice for women with significant symptoms. Hence in a patient, when the patient is suffering for sometime with poor quality of life, with partial relief from medication, then it is a better and wise option to go for a laproscopic uterus removal ( TOTAL LAPAROSOCPIC HYSTERECTOMY).The patient can undergo the surgery with 3 mm and 1cm holes with minimal scars, minimal pain, early ambulation, early discharge, early recovery and early return to work. https://www.youtube.com/watch?v=Yz1N8-RaWVE :laparoscopic removal of uterus with adenomyosis by DR G S S MOHAPATRA
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      TAKE HOME MESSAGE IN ENDOMETRIOSIS:

      • FIRST SURGERY IS THE MOST IMPORTANT SURGERY..SO DO IT WITH A PERSON SKILLED IN DOING SUCH COMPLEX SURGERIES LIKE WE DO AT MY CENTRE.
      • ENDOMETRIOSIS HAS A RECURRENCE RATE OF UPTO 40 % IN 5 YEARS. SO DO A CAREFUL FOLLOW UP
      • IF YOU ARE INFERTILE AND HAVING ENDOMETRIOSIS, THEN YOU NEED TO ACT FAST AND ALWAYS BE ALERT BECAUSE ON A LONG TERM, ENDOMETRIOSIS AFFECTS EGG QUALITY,HINDERS IMPLANTATION,CAUSES PELVIC ADHESIONS WHICH INTERFERE WITH INFERTILITY