karusmle
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Six month after the delivery of her fourth child, a 37-year-old woman undergoes laparoscopic tubal ligation. Menses occur at regular 28-day
intervails. During the operation, she is found to have a small dark lesion in the cul-de-sac and falmy adhesionsw surrounding the ovaries. A biopsy specimen of a cul-de-sac lesion confirms the diagnosis of endometriosis. Which of the following is the most appropriate next step in management?
A) Danazol therapy
B) Gonadotropin-releasing hormone agoinst therapy
C) Oral contraceptive therapy
D) Total abdominal hysterectomy and bilateral salpingo-
oophorectomy
E) No futher treatment indicated.
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| divya888
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E) No futher treatment indicated.
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| MAZI
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CORRECT ANSWER IS D
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| sachida
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I go for E. Pt is asymptomatic and still fertile. Choosing D seems extreme and negates future pregnancy desires. Tubal ligation just means she does not want pregnancy for now.
If symptoms arise then she should get OC pills with NSAIDs
Other means to treat include:
Psuedopregnancy- using provera or medroxyprogesterone
Pseudomenopause- using dnazol (androgen related side effects) or GnRH agonist luperon (estrogen deficiency side effects).
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| drhyd
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Even i go for E:
Pt is asymptomatic and condition is not premalignant.
If pt is asymptomatic or minmally symptomatic expectant mangament.
Surgery is the definitive treatment.
Pseudo pegnancy and pseudomenopause are temporary( relieves only symptomatically and atrophies.
TAH is reserved when symptomps are sevre and refractory to conservative medical and surgical mangament..
Sachida Tubal ligation is considered as a permanant sterilisation, not temporary.
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| MAZI
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i think you are right
what,s the correct answer karusmle
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| AAAAA
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MAZI wrote:
CORRECT ANSWER IS D
I have done quite a few laparoscopies for patients with chronic pelvis pain and made the diagnosis of endometriosis and my Professor NEVER do a case of TAH-BSO !!
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| AAAAA
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Endometriosis is a progressive disease affecting 5 to 10 percent of women. It can cause dyspareunia, dysmenorrhea, low back pain and infertility. A definitive diagnosis can be made only by means of laparoscopy. Medical treatment designed to interfere with ovulation generally provides effective pain relief, but the recurrence rate following cessation of therapy is high, and this type of treatment will not resolve infertility. Surgical treatment improves pregnancy rates and is the preferred initial treatment for infertility caused by endometriosis. Surgery also appears to provide better long-term pain relief than medical treatment.
Bilateral oophorectomy and hysterectomy are treatment options for patients with intractable pain, "if childbearing is no longer desired" 
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| AAAAA
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Surgical treatment improves pregnancy rates and is the preferred initial treatment for infertility caused by endometriosis. Surgery also appears to provide better long-term pain relief than medical treatment.
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| AAAAA
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Recently, an empiric three-month trial of therapy with gonadotropin-releasing hormone (GnRH) analogs has been a popular strategy.16
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| AAAAA
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Medical treatment may be used for superficial instead of deep peritoneal implants and less severe chronic pain
Medical Management: Medical management can be relatively effective for moderate endometriosis, particularly for women with superficial rather than deep peritoneal implants. When endometriosis involves the ovaries, the response to medication is usually not as good
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| AAAAA
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When endometriosis involves the ovaries, the response to medication is usually not as good
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| AAAAA
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During the operation, she is found to have a small dark lesion in the cul-de-sac and falmy adhesionsw surrounding the ovaries. A biopsy specimen of a cul-de-sac lesion confirms the diagnosis of endometriosis. Which of the following is the most appropriate next step in management?
A) Danazol therapy
B) Gonadotropin-releasing hormone agoinst therapy
C) Oral contraceptive therapy
D) Total abdominal hysterectomy and bilateral salpingo-
oophorectomy
E) No futher treatment indicated.
She is asymptomatic and who knows what the dark lesion is.
I did quite a few laparoscopies and the lesions were somewhat yellowish and not dark lesions. so I would not do anything at all.
The diagnosis have not even made yet for endometriosis !
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| AAAAA
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There are many different discolorations on laparoscopic examinations
Classic endometriosis appears as small, raised, bluish areas that have been described as “powder burns” or “blueberry spots.” However, biopsies have confirmed that white and lighter red raised areas, filmy adhesions and peritoneal defects, as well as advanced areas of scarring and adhesions, can be due to endometrial implants.
As seen in the photographs to the right, endometriosis can be red or yellow, raised 'bumps' or 'holes.' Any appearance that does not appear smooth and shiny is compatible with pathologic endometriosis.
Treatment: The treatment of endometriosis should be individualized according to the needs of each patient. Generally, the most common approaches are with hormonal therapy, laparoscopic surgery and major surgical management. In the past, it was thought that pregnancy would “cure” endometriosis. It is now recognized, however that the disease will persist and recur after pregnancy. Hormonal treatment, which is probably most effective when the areas of endometriosis are small, includes the use of oral contraceptives on a continuous basis. The combination of estrogen and progestin oral contraceptives may alleviate cyclic pain by suppressing the cyclic growth of endometriotic patches. However, success seems to be limited to the younger patient with milder disease. Danazol, a steroid androgen, more substantially suppresses the cyclic changes and thereafter causes atrophy of the endometriotic sites. Newer medications called GnRH agonists (Lupron, Synarel, Zoladex) suppress the ovary by blocking the release of pituitary hormones. These agents do not have the acne and weight gain side effects of Danazol. For others, an agent containing a progesterone derivative is used. In my research, each drug offers specific benefits although all may produce osteoporosis (bone thinning) with prolonged use. Quantitative analysis of serum hormonal levels on these drug regimens allows the evaluation of estrogen, androgen and progesterone suppression.
Surgical Intervention: When infertility is not a factor and the patient present with dsymenorrhea and/or dyspareunia, the medical approach may be provided prior to diagnostic surgery. However, after drug therapy the if the patient experiences a progression of the disease as determined with pelvic examination and/or ultrasound, or remains symptomatic, then operative intervention may be required. Prior to drug therapy for infertility, in light of the fact that medication is expensive, that there are side-effects and that pregnancy should be prevented while on such drug regimes, it is beneficial to confirm the diagnosis is endometriosis. Further, it is important to stage the disease in order to prescribe the appropriate modality of therapy. And the most efficacious method of diagnosis and staging endometriosis is with laparoscopy.
Through the laparoscope, not only can endometrial lesions be identified, but endometriotic areas can be fulgurated (burned) and adhesions lysed. With the addition of laser, through the laparoscope even extensive endometriotic tissue can be vaporized and adhesions removed. Furthermore, Laparoscopic Uterine Nerve Ablation, L.U.N.A. and subsequent nerve interrupting surgery has been the most effective modalities for relief of pain sans hysterectomy since we first performed the procedure in 1982. The laser vaporization of lesions at the time of laparoscopy affords the physician a means of treatment at the time of diagnosis. In fact, in hundred of my patients, laser laparoscopy has become the primary mode of therapy.
In skilled hands, the risks of L.U.N.A. or laser surgery can be less than conventional ‘open’ incisions. L.U.N.A. research confirmed that the transection of the uterosacral nerves has its only action by releasing the uterine spasm and allowing the menstrual blood to egress more quickly. Whether the surgeon relies on L.U.N.A. or presacral neurectomy, the procedure has a 50-70% success at relieving painful menstrual periods.
Conclusion: The key point in discussing the medical and surgical management of menstrual pain and endometriosis is the recognition that these conditions affect millions of individuals in the United States alone. For fifty years, most women with menstrual pain were though to be psychosomatic. We now know that menstrual pain is real whether endometriosis is seen or not! Therefore, a woman need not continue to suffer and believe that the pain is “in her head.” It should never be considered a psychosomatic illness. From a research finding of extreme uterine contractions, to laparoscopic findings of endometriosis, to proof of pain relief by surgical and medical therapies, we understand that menstrual pain is real and the sufferer deserves appropriate medical consideration.
retrograde blood in cul-de-sac
endometriosis 'blebs' and increased vasculature
clear 'blisters'
red-brown endometriosis
endometriosis on insertion of utero-sacral ligaments at cervix
endometriosis on left utero-sacral vaporized (LUNA) with endometriosis on broad ligament at X
--------------------------------------------------------------------------------
Other patients
L.U.N.A. Surgery as Appears in Journal of Reproductive Medicine Article
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| AAAAA
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Posts: 1,991
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In the past, it was thought that pregnancy would “cure” endometriosis. It is now recognized, however that the disease will persist and recur after pregnancy. Hormonal treatment, which is probably most effective when the areas of endometriosis are small, includes the use of oral contraceptives on a continuous basis. The combination of estrogen and progestin oral contraceptives may alleviate cyclic pain by suppressing the cyclic growth of endometriotic patches. However, success seems to be limited to the younger patient with milder disease. Danazol, a steroid androgen, more substantially suppresses the cyclic changes and thereafter causes atrophy of the endometriotic sites. Newer medications called GnRH agonists (Lupron, Synarel, Zoladex) suppress the ovary by blocking the release of pituitary hormones. These agents do not have the acne and weight gain side effects of Danazol. For others, an agent containing a progesterone derivative is used. In my research, each drug offers specific benefits although all may produce osteoporosis (bone thinning) with prolonged use. Quantitative analysis of serum hormonal levels on these drug regimens allows the evaluation of estrogen, androgen and progesterone suppression.
Surgical Intervention: When infertility is not a factor and the patient present with dsymenorrhea and/or dyspareunia, the medical approach may be provided prior to diagnostic surgery. However, after drug therapy the if the patient experiences a progression of the disease as determined with pelvic examination and/or ultrasound, or remains symptomatic, then operative intervention may be required. Prior to drug therapy for infertility, in light of the fact that medication is expensive, that there are side-effects and that pregnancy should be prevented while on such drug regimes, it is beneficial to confirm the diagnosis is endometriosis. Further, it is important to stage the disease in order to prescribe the appropriate modality of therapy. And the most efficacious method of diagnosis and staging endometriosis is with laparoscopy.
Through the laparoscope, not only can endometrial lesions be identified, but endometriotic areas can be fulgurated (burned) and adhesions lysed. With the addition of laser, through the laparoscope even extensive endometriotic tissue can be vaporized and adhesions removed. Furthermore, Laparoscopic Uterine Nerve Ablation, L.U.N.A. and subsequent nerve interrupting surgery has been the most effective modalities for relief of pain sans hysterectomy since we first performed the procedure in 1982. The laser vaporization of lesions at the time of laparoscopy affords the physician a means of treatment at the time of diagnosis. In fact, in hundred of my patients, laser laparoscopy has become the primary mode of therapy.
In skilled hands, the risks of L.U.N.A. or laser surgery can be less than conventional ‘open’ incisions. L.U.N.A. research confirmed that the transection of the uterosacral nerves has its only action by releasing the uterine spasm and allowing the menstrual blood to egress more quickly. Whether the surgeon relies on L.U.N.A. or presacral neurectomy, the procedure has a 50-70% success at relieving painful menstrual periods.
Conclusion: The key point in discussing the medical and surgical management of menstrual pain and endometriosis is the recognition that these conditions affect millions of individuals in the United States alone. For fifty years, most women with menstrual pain were though to be psychosomatic. We now know that menstrual pain is real whether endometriosis is seen or not! Therefore, a woman need not continue to suffer and believe that the pain is “in her head.” It should never be considered a psychosomatic illness. From a research finding of extreme uterine contractions, to laparoscopic findings of endometriosis, to proof of pain relief by surgical and medical therapies, we understand that menstrual pain is real and the sufferer deserves appropriate medical consideration.
retrograde blood in cul-de-sac
endometriosis 'blebs' and increased vasculature
clear 'blisters'
red-brown endometriosis
endometriosis on insertion of utero-sacral ligaments at cervix
endometriosis on left utero-sacral vaporized (LUNA) with endometriosis on broad ligament at X
--------------------------------------------------------------------------------
Other patients
L.U.N.A. Surgery as Appears in Journal of Reproductive Medicine Article
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