Andrea Fiaccavento MD Endometriosi ape 2015

C.I.E.
Centro Interdiscilinare Endometriosi
CDC Pederzoli
Peschiera del Garda ( VR)
CastelCovati 11/04/2015
Endometriosi pelvica:
come riconoscerla, trattarla
e sconfiggerla
Andrea Fiaccavento MD
responsabile CIE CdC Pederzoli
Endometriosi
Viene definita come la presenza di ghiandole
endometriali e stroma al di fuori della cavità
uterina, spesso associata a dolore pelvico,
infertilità e masse annessiali.
Si manifesta con cisti
endometriosiche, fibrosi,
aderenze a volte di tale
gravità da sovvertire
l’apparato riproduttivo
della donna
Prefazione
Clinical management of DIE
= Big
problem:
complex disease
Different clinical
implications
Deeply infiltranting endometriosis
First problem: what do we talk about?
different classifications
different definitions
Pathogenesis unclear
Possible variants of the disease
We often do not speak the same language
Deeply Infiltrating Endometriosis
ENDOMETRIOTIC IMPLANTS THAT PENETRATE BELOW
THE SURFACE OF PERITONEUM MORE THAN 5 mm ARE
DEFINED INVASIVE OR INFILTRATING
retroperitoneo
peritoneo
endometrioma
DIE vescicale
Areas of involvement
1. 60% uterosacral ligaments and rectovaginal
septum
2. 50% ovaries
3. 3-36% Bowel (rectum and sigma 72-85%)
4. 15-20% Urinary System
5. 10% fallopian tubes
6. 8% Extrapelvic
60% of DIE involves
neurological risk areas
utero
Endometriosi
peritoneale
retto
uretere
Nervo
ipogastrico
Vasi iliaci
esterni
DIE
the high risk areas
uterus
ovary
rectum
scr
o
r
ute
u
ro
e
t
al
r
sc
nt
e
m
a
g
li
ent
m
a
al lig
RV septum
Rectovaginal septum
RV septum
Endo nodule
Rectal wing (cut)
Rectum-mesorectum
Pelvic floor
DEEP INFILTRATING ENDOMETRIOSIS (DIE)
It is associated with chronic pelvic pain, dyspareunia, severe
menstrual pain, painful defecation, dysuria and back pain
QOL significantly compromised
DEEP INFILTRATING ENDOMETRIOSIS (DIE)
Right
Umbilical artery
Second problem
Pathophysiology of the disease
Right
•
•
•
•
•
•
•
•
IHP
Chronic disease - relapse
Multifocal and multicentric
spread
Evolving nature
Progresses along neurovascular structures and ligaments
It is associated with phenomena of neoangiogenesis
Invades the perineural and endoneural spaces
Compressive and infiltrative capacity on hollow viscera
Clinical implications
Third Problem
ü high prevalence in the female population
ü young patients
ü important symptoms - Chronic Pelvic Pain
ü infertility
ü QOL
ü psychological implications
ü high social cost
Da studi effettuati risulta che l’endometriosi è
una malattia che ha una grande interferenza sulla
qualità della vita, determinando:
1. disturbi del sonno (81%)
2. influenze negative sul lavoro (79%)
3. rapporti sessuali dolorosi se non impossibili,
con conseguenze nel rapporto di coppia (77%)
4. influenza negativa sulla propria vita sociale
(73%).
epidemiology
ü 10% of European Women
ü 2-4% postmenopouse
ü 10% < 20yrs
ü 30% al 40% infertility - 40-70% pain
ü 3 milons italian women affected by DIE
ü 30 bilion dollars EU work related
ü delay in diagnosis on average 7.2 years
9579 euro anno/ donne
6298 perdita prod
3133 ass san.
Management of DIE
1. Diagnosis
2. Staging
3. Treatment
4. Follow-up
Diagnosis
first step:
identification of the disease
importance of an early diagnosis
secondo step :
Staging
Identification of anatomical sites of infiltration
of the disease
therapeutic strategy
Diagnosis
1. History (symptoms are of great importance for
the suspicion of disease, to choose the
treatment plan and surgery)
2. Examination
3. Imaging
4. Surgery
5. Markers ?
6. histology
Hystory
do you have pain ?
The most common symptoms of Endometriosis
- Pain before and during periods
- Pain with intercourse
- General, chronic pelvic pain throughout the month
- Low back pain
- Painful bowel movements, especially during
menstruation
- Painful urination during menstruation
- Fatigue
- Infertility
- Diarrhoea or constipation
Other symptoms are common with Endometriosis:
- Headaches
- Low grade fevers
- Depression
- Anxiety
- Susceptibility to infections, allergies
Other immune system associated problems:
- Chronic
Fatigue Syndrome
- ME Hypothyroidism
- Fibromyalgia
- Rheumatoid arthritis
Pay attention to the symtoms!!
For many women there is a significant delay in diagnosis, with
studies showing a mean delay of 11.7 years in the US compared
with an 8-year delay in the UK,7 and a 6.7-year delay in Norway
Hadfield et al1996 - Husby et al., 2003
Considerable diagnostic delay of up to 8 years from
presenting symptoms often confers a heavy economic and
social price
Ballard et al., 2006
Diagnosis :examination
vaginal exploration
rectal examination
bimanual vaginal examination
examination
Medial to uterosacral
ligament
Rectovaginal septum
Rectovaginal ligament
Pararectal space
Lateral to uterosacral
ligament
Parametrium
Paracervix
Ercoli Am J Obstet Gynecol 2005
imaging
“On the basis of our data and the availability of TVS and
PV, these modalities can be recommended as the
method of choice for the primary and preoperative
assessment of pelvic pain patients with suspected
endometriosis”
Transvaginal ultrasonography and certainly the method
with the best cost-benefit ratio in diagnosio of deep
endometriosis. MRI best sensitivity and PPV for the
uterosacral ligaments and vagina
•
•
•
•
•
Timing of pain
Kind of pain
Sites of pain
Intensity of the pain ( VAS)
Impact of pain on QoL
• Sites of lesions
• Topography of lesions on:
• genital tract
• bowel
• urinary tract
diagnosis
staging
treatment
staging
Major problem lacking of classifications useful to:
to correlate Outcomes with disease stage to
identify prognostic factors allows choosing the
treatment strategy in relation to the stage of the
disease.
Furthermore an ideal classification should be
simple and reproducible It is not possible to
compare the data
DIE classification
(Chapron et al, Hum Reprod, 2003)
ENZIAN-score, a
classification of
deep infiltrating
endometriosis
Zentralbl Gynakol. 2005.
ASRM (1996)
Diagnosis and staging : main goal
Identify anatomical sites infiltrated by
endometriosis to determine the evolutionary stage
of the disease, plan a therapeutic strategy and to
provide a prognosis to the patient
Reproductive System
gastrointestinal
Visit + imaging
urinary
Markers?
nerve plexus
extrapelvic endometriosis
imaging
diagnostic tools
RMN
RMN
Double contrast enema
Hystologic
Clisma opaco
Urografia
Our strategy in choosing diagnostic tools
for diagnosis and staging
first step :
Visit with identification mobility of the uterus,
uterosacral thickening, nodules in Douglas and the
posterior or anterior vaginal fornix, invasion of the
lateral or anterior parametrium
second step : imaging
evaluation anterior compartment: bladder
assessment anterior compartment: Douglas and
uterosacral ligament and uterine torus
assessment retroperitoneum
assessment rectum
assessment ureters
Conclusions
We have many tools for adequate diagnosis and staging but in
a context of cost-effectiveness we have to consider what
we really need to have a correct strategy of treatment.
we have to rely on our own resources and work
as a team for endometriosis, so that the
diagnostic exam, depends on the operator who
performs
Where?
DIE center
Gynaecological
General
Bowel
Bladder
Lung
IVF
Reproductive endocrinologists ICSI
IUI
Surgeons
Immunologists
Psychologists/counsellors
the decision making team
Nurses
Telephone
Online
Meetings
Literature
Onsite support
Nutritionists
WOMAN
and
GYNAECOLOGIST
Patient support groups
Pain management
Physiotherapy
Massage
Acupuncture
Stress mgmt
Exercise
TCM
Complementary therapies Homeopathy
Reflexology
Herbalists
D'Hooghe and Hummelshoj, Hum Reprod 2006;21(11):2743-8
Opzioni di trattamento
nulla
medico
chirurgico
medico + chirurgico
main goal :
migliorare QOL delle PZ:
ridurre il dolore
incrementeare la fertilità
ritardare le recidive
evitare importanti sequele
endometriosis should be viewed as a chronic disease
that requires a life-long management plan with the goal of
maximizing the use of medical treatment and avoiding
repeated surgical procedures.”
-”
Practice Committee of the American Society for Reproductive Medicine 2008
problemi correlati al trattamento
molte variabili
sintomi
fertilità
fattori di rischio per importanti
sequele
recidive
effetti collaterali terapia medica
complicanze terapia chirurgica
rischi e benefici
90
Migliorare QOL delle
pazienti
ENDOMETRIOSI PAZIENTI
trattamento in italia
Pazienti con endometriosi
> 1.000.000 (10%)
Diagnosticate
Sospette
600.000 (60%)
400.000 (40%)
Trattate con
farmaci
Trattamento
chirurgico
Trattate con
farmaci
Non trattate
400.000 (70%)
180.000 (30%)
240.000 (60%)
160.000 (40%)
Medical treatment
da dove partiamo?: esperienze della letteratura
medical therapy
ENDOMETRIOSI
EVOLUZIONE TERAPEUTICA
CO
GnRh-a
Danazolo
vecchi
Progestinici
‘80
‘00
2013
nuovi
Progestinici
‘90
Chirurgia
DIENOGEST 2 MG
obiettivo : avere prodotto che fornisca forte efficacia sul dolore,
insieme alla sicurezza per un trattamento a lungo termine, alla
favorevole tollerabilità e l’esplicita indicazione per
l’endometriosi.
ENDOMETRIOSI Italia 2012
I TRATTAMENTI FARMACOLOGICI
Altri
farmaci
Danatrol
Progestinici
Analgesici
Contraccettivi
ormonali
25%
43%
Mercilon
Cerazette
Yaz
Klaira
32%
GnRHanaloghi
Enantone Depot
Decapeptyl
Zoladex
Fonte: SPM 2012 – Prescrizioni per Endometriosi
PRESCRIZIONI PER ENDOMETRIOSI
2012: +15%
elements in favor of medical therapy?
undoubtedly medical therapy has an important role in the
management of endometriosis
Medical therapy is effective in reducing pain (Fedele, 2000;
Vercellini, 2005; Remorgida, 2007)
you can 'have a partial reduction or at least an arrest of
the disease during medical therapy (Fedele 2000, 2001; Vercellini
2005, 2009)
Radical surgery of endometriosis is difficult and has a
high rate of complications in the literature (Vercellini et al.,
2004, 2009)
recurrence after surgery> 20%
additional surgery in 25% PZ
elements in favor of a surgical therapy
DIE is a benign disease with a tendency to progression with risk of
major sequelae (Fedele 2004; Carmignani, 2009)
obstructive uropathy, intestinal stenosis, symptomatic adnexal cysts
of uncertain nature
desire of pregnancies
70-80% reduction in pain after surgery
pcs unresponsive or with contraindications to medical therapy
Chronic medical therapy - recurrence of the disease after stopping
TM (Vercellini)
infiltrating lesions appear to be insensitive to medical therapy
(Nezhat, Br J Gynecol Obstst '92)
what should be a logical therapeutic
strategy?
First diagnosis e staging
determine if surgery is MANDATORY
intestinal stenosis> 60%?
ureteral obstruction!
infiltration parameters and nerve plexus!
high risk of bowel obstruction
high risk of renal failure
high risk of neurological impairment
what should be a logical therapeutic
strategy?
second: identifying the risks of disease progression
young patients
symptomatic
signs of deep infiltration of the disease
R - V septum
vagina
parameters
bilateral ovarian cysts
intestinal involvement
risk of significant sequelae (Fedele 2004; Carmignani,2009)
Third: careful evaluation of clinical variables
cyclic VS continuous pain
desire of pregnancies
previous surgery
failure of medical therapy
cancer risk
All variables must be condiderate with the aim of
finding the best treatment for the individual patient
rational treatment
cyclic pain
previous surgery / recurrent
the absence of risk factors
medical therapy
failure of medical therapy
Surgery
presence of risk factors
of evolution of the
disease or of sequelae
conic constant pain
contraindications to
medical therapy
desire of pregnancy
BUT
Before operation
presurgical staging of the disease
careful surgical planning: duration, type of intervention
planning for multi-disciplinary approach
informed consent
Goal of conservative surgery:
Maintain reproductive function
Treat the painful symptoms
Preserve organ function
To minimize the sequelae and
complications
4- Follow-up post & surgical trattament
While the aetiology of endometriosis is still
unknown, it is likely that the biological
mechanisms responsible for endometriotic
implants are not influenced by surgery, and that
new lesions may form as soon as the day after the
surgical procedure. This hypothesis provides an
explanation as to why the risk of pain
recurrences may average 20–40% at only 3–5
years after the surgery
(Vercellini et al., 2009)
follow-up
It has been shown that continuous postoperative hormonal treatment might
prevent pain recurrences after surgical
removal of deep infiltrating nodules
(Donnez and Squifflet, 2010
Conclusione
§ Endometriosis is a complex disease with a
big impact on society and on the lives of
many women.
§ The disease management necessarily
requires a multidisciplinary approach in
centers of reference in order to improve
treatment outcomes and optimize the cost
and benefits.
Thank for your kind attention
Andrea Fiaccavento MD
OB/GYN Dept.
Casa di cura Dott Pederzoli
Peschiera D/G, Verona , Italy