Endometriosis 3qly

REFERAT

KISTA ENDOMETRIOSIS Preseptor: dr. Jerry Indrawan, Sp.OG

5/23/2018

S. Ranny Yulia Effendi 130611012

Bagian/SMF Obstetri dan Ginekologi Fakultas Kedokteran Universitas Malikussaleh Rumah Sakit Umum Cut Meutia Aceh Utara 2018

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PENDAHULUAN

Definisi

Risk factor & Protective factor

Patofisiologi

• Menurut topografinya endometriosis dapat digolongkan, yaitu sebagai berikut: – Endometriosis Interna • Endometriosis didalam miometrium (uterus)/di dalam uterus  adenomiosis • Letaknya didalam tuba  adenomiosis ismika nodosa, hematosalping. – Endometriosis Eksterna Endometriosis di luar uterus “true endometriosis”, letaknya: - di dinding belakang uterus, - dibagian luar tuba - di ovarium (di pelvio-peritonium dan di cavum Douglasi, rekto-sigmoid, kandung kencing, umbilikus sampai pada kulit dan paru paru-paru).

• Endometriosis dapat dikelompokkan menjadi 3 kategori berdasarkan lokasi dan tipe lesi,yaitu: • Ovarian Endometrial Cysts (Endometrioma) terbentuk akibat invaginasi dari korteks ovarium setelah penimbunan debris menstruasi dari perdarahan jaringan endometriosis. Kista endometrium bisa besar (>3cm) dan multilokus, dan bisa tampak seperti kista coklat karena penimbunan darah dan debris ke dalam rongga kista. • Deep Nodular Endometriosis jaringan ektopik menginfiltrasi septum rektovaginal atau struktur fibromuskuler pelvis seperti uterosakral dan ligamentum utero-ovarium. Nodul-nodul dibentuk oleh hiperplasia otot polos dan jaringan fibrosis di sekitar jaringan yang menginfiltrasi. Jaringan endometriosis akan tertutup sebagai nodul, dan tidak ada perdarahan secara klinis • Peritoneal endometriosis Pada awalnya lesi di peritoneum akan banyak tumbuh vaskularisasi sehingga menimbulkan perdarahan saat menstruasi. Lesi yang aktif akan menyebabkan timbulnya perdarahan kronik rekuren dan reaksi inflamasi sehingga tumbuh jaringan fibrosis dan sembuh. Lesi berwarna merah dapat berubah menjadi lesi hitam tipikal dan setelah itu lesi akan berubah menjadi lesi putih yang miskin vaskularisasi dan ditemukan debris glandular.

Manifestasi klinik

Sites of endometriosis • Pelvic – Ovary – Cul de sac – Uterosacrals – Posterior surface of uterus – Posterior broad ligament – Rectovaginal septum – Tubes and round ligaments • Extrapelvic sites – Intestines (rectosigmoid, cecum, terminal ileum, proximal colon, appendix)

– Lungs & thorax – Urinary tract

• Less common sites – – – –

Cervix Hernial sacs Umblicus Laparotomy/episiotomy sites – Tubal stumps after sterilization

• Rarest – Extremities

Diagnosis • Anamnesis • Pemeriksaan fisik • Pemeriksaan penunjang

LAPAROSKOPI  GOLD STANDAR

Laparoscopic photographs Ovarian endometrioma: chocolate cyst Ovarian endometrioma: “kissing ovaries”

Peritoneal endometriosis

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Pemeriksaan fisik 1. Inspeksi vagina dg spekulum 2. Dilanjutkan dengan: - Pemeriksaan bimanual menilai ukuran, posisi, mobilitas uterus - Palpasi rectovagina  mempalpasi ligamentum sakrouterina dan septum rektovagina (unutk mencari ada atau tidaknya nodul endometriosis) *saat haid  meningkatkan peluang mendeteksi nodul endometriosis dan menilai nyeri

Pemeriksaan penunjang (*khas) • USG (abdominal/transvaginal)  Pemeriksaan penunjang lini pertama  Tetapi tidak baik untuk mendeteksi endometriosis di peritoneal • MRI  Baik untuk mendiagnosis endometrium ektopik (peritoneal) • Lab  pemeriksaan marker biokimia  IL-6 (membedakan wanita dengan atau tanpa endometriosis)  IL-6 dan TNF-α (penanda yang baik untuk diagnosis endometriosis gejala ringan-sedang)  CA125, Hs-CRP dan VEGF (meningkat pada kasus yang sudah lama terjadi, sehingga tidak dapat digunakan untuk mendiagnosis kasus baru endometriosis)

Biopsi

• A:kista endometriotik  kista coklat tdd darah yang mengalami degenerasi • B: stroma endometrium ttd: - sel-sel stroma gemuk (khas perubahan desidual) - Bagian tengah tampak banyak magrofag yg mengandung hemosiderin

Diagnosis Banding Dibedakan berdasarkan: 1. Ginekologi 2. Non ginekologi

Klasifikasi • AFSASRMmerevisi lagi sistem klasifikasinya, yang dikenal dengan sistem skoring revised-AFS (r-AFS) • Menurut ASRM, Endometriosisdiklasifikasikan kedalam 4 derajat keparahan tergantung pada lokasi, luas, kedalaman implantasi dari sel endometriosis, adanya perlengketan, dan ukuran dari endometrioma ovarium. • -

yakni: Stadium I (minimal) : 1-5 Stadium II (ringan) : 6-15 Stadium III (sedang) : 16-40 Stadium IV (berat) : >40

Walaupun tidak ada perubahan staging dari klasifikasi tahun 1985 sistem klasifikasi tahun 1996 memberikan deskripsi morfologi lesi endometriosis, yakni putih, merah, dan hitam.

TATALAKSANA

Treatment goals • To alleviate pains • To delay recurrence as long as possible • To help patients get pregnant

Treatment Options • Medical Therapy – NSAIDs and Cox2 inhibitors – COCs – Progestogens – Anti progestins – GnRH agonists and antagonists  Aromatase inhibitors  Selective Estrogen Receptor Modulators

•

Selective Progesteron Receptor Modulators

• Surgical Treatment – Conservative Surgery – Definitive Surgery

Treatment options • Thoughts before deciding the treatment – Symptoms • Pain or infertility or both

– Patient characteristics • • • • • •

Age Severity of disease Severity of pain Prior treatment history Reproductive needs Other wishes

Some rough guidelines • First-line medical treatment: patients with mild symptoms or adolascent girls • Medical treatment: Patients with endometriosis who wish to get pregnant • Fertility-preserving surgery: Young patients with severe endometriosis who wishes to have children • Ovary-preserving surgery+medication: young patients with severe endometriosis who does not wish to have children • Radical surgery: Older patients with severe endometriosis who do not wish to have children

Treatment options • Surgery – Laparoscopy or laparotomy – Radical or conservative

• Non-surgical treatment (medication) – – – – – –

First-line medication Progestins Gonadotropin-releasing hormone (GnRH) agonists Danazol (androgenic) Oral contraceptives Controlled ovarian hyperstimulation (fertility treatment)

Surgery -Indications Medical treatment ineffective Size of the adnexal mass > 5 cm Wishing to get pregnant -Purposes Accurate diagnosis Removal of endometriotic lesions as much as possible Removal of adhesion and restoration of normal anatomy

-Pros Proven efficacy

-Cons Invasive Costly Certain risks Due to high recurrence risk (~50% 5 yrs), 2nd surgery may be needed Increases the risk of damaging ovaries, and the risk of premature ovarian failure

Medical treatment: Expectant treatment • Use NSAIDs – Asprin – Other analgesics such as ibuproten – Selective COX-2 inhibitors – Little impact, if any, on endometriotic lesions

• Follow-up

Medical treatment • Principles (for current treatment modalities) – To suppress ovarian estrogen production (GnRH-a and danazol) necessary for the development and maintenance of ectopic endometrium – To induce a pseudo-pregnency (progestins and OC), which suppresses ovulation and estrogen production – With reduced estrogen production, endometriotic lesions may shrink in size or may be eliminated • All are short-term; recurrence after termination • All have various side-effects • ~10% simply do not respond to pregestin therapy

Progestin treatment • Based on a serendipitous finding that pregnancy relieves the sysmptoms of endometriosis • Mechanism of action (MOA) • Suppresses ovulation • Suppress the growth of endometriotic lesions • Reduce inflammation

• Progestins – Oral • Norethisterone acetate • Cyproterone acetate • Dienogest

– Intramuscular route • Medroxiprogesterone acetate

– Intrauterine route • Levonorgestrel-releasing IUD

• Side-effects – Spotting, hot-flashes, breakthrough bleeding

GnRH agonists treatment • MOA – Negative control of ovarian estrogen production • Method of istration – Injection • Side-effects – Hot-flashes – loss of libido – vaginal dryness, – decreased bone density • Quite expensive

Danazol treatment • Danazol is a modified androgen • 2.5-3.5% of activity of methyl testosterone

• MOA – Antagonizes estrogen at the tissue level • Blocks estrogen receptor sites – Suppresses ovulation (and thus estrogen production) • Alters pulsatile GnRH release patterns

• Side-effects: weight gain, acne, hirsutism, … • Decreased use after GnRHa introduction

Treatment with oral contractives • MOA – Suppresses ovulation – Induces a psudopregnancy state

• Not approved by the USFDA yet • Often used as an “empirical” treatment (w/o a firm Dx) • Pros – Low cost – Easy – Addition to contraception

• Cons – Not good for women who wish to get pregnant

Other medical treatment • Traditional Chinese medicine – A recent review indicates that evidence is not there due to poor quality

• Mifepristone (RU486) – Inadequate evidence

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