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Um And I have a particular interest in endometriosis, um medical and surgical management. Um There, this is quite timely, I think partly because obviously it is Endometriosis Awareness Month, which slightly embarrassingly I wasn't aware of until I was told by, by these guys last couple of weeks ago. Um But also if you've been picking on, on the news, there have been a few articles recently about the state of endometriosis care um in this country over the past few years. Um some of which um have more clinical go here and see them than others. But anyway, um this is something that we are going to hear a lot about. It is a very topic at the moment. Um So what I'm hoping to talk about today with that in mind is a little bit about what endometriosis is. How do we diagnose it? How does it present? Um And then how do you manage it? And I'm gonna touch, if we have time, I'm gonna touch briefly on the impact of fertility because this is something that is a known problem. Um But the er underpinning mechanisms and the best treatment options are still relatively poorly understood. Um That's a big controversial area at the moment. So, first of all, what is endometriosis? Um as most of, you know, endometriosis is a condition characterized by the presence of endometrial like tissue outside of the endometrial cavity. So, most commonly that will be on the outside of the uterus on the fallopian tubes, on the ovaries, the peritoneum on the Douglas cover ligaments. Um but you can get it anywhere in the peritoneum. You can get it on the back, you can get it on the bladder, you can get it on the phrag, you can get it in the chest. Um So it can be all over the shop. Um And the key thing with this is that it uh causes a chronic inflammatory reaction. So the initial insult may be um bleeding from endometrium, but the long term consequences of that are chronic inflammation. Um The etiology is uncertain. We don't actually know why it happens. We used to think things like retrograde menstruation. So that's during your period, a small amount of blood will come through the fallopian tubes rather than coming out of the cervix. Um That doesn't explain how it gets into your chest. So it's probably in part of the story, but it's not um not the whole story by any means. Um And with the classification system, it's again, quite controversial, you'll hear lots of people talk about lots of different things for me. I like um this classification. It's quite simple. Um where we basically subdivide it into what it looks like and where it is. So most common would be what's called superficial peritoneal disease. So that's where this endometriosis sits on the peritoneum c and it's not invading into organs. And that counts for about 75 80%. Ovarian endometriosis, which is commonly in the form of endometriomas. So, ovarian cysts filled with blood, um that counts for around 15 to 20% and then deep infiltrating, endometriosis is the least common kind, but this is the most kind of serious in terms of complications if you like. And this is the one that invades into the wall of the bladder, into the bowel into the diaphragm, those kind of things. Um And the management of the three different types, um is different and we'll come onto that later. So this is just some pictures illustrating what we're talking about the big one and it made it big. Um because it's most common is superficial endometriosis. So, what we're looking at here is the pouch of Douglas. So this is the pouch of peritoneum between the back wall of the uterus and vagina and the rectum. Um And you can just see the rectum at the back, little bit of fatty blobs covering the large bowel there. Um, some blood stain fluid in the Douglas, which is probably from surgery. And then the sort of the U shaped ligament that you can see is the U sacral ligament and those sort of dotty red bits on the surface are endometriosis. It doesn't always look like that. It can be subtle. And sometimes all we see is the um kind of injection. So the increased vascularity, the just the general redness of the tissue um is increased when you've got a chronic inflammatory disease like endometriosis. And sometimes that's all the top right hand picture is an ovary. Um, so the sort of cystic structure on the left hand side, there's a dark brown, black color is the ovarian c. It's been burst in surgery and there is um the chocolate like contents coming out. So those cysts are classically called chocolate cysts cos it does look like melted dairy milk coming out when you burst them. Um And then the bottom right hand picture, um shows deep infiltrating endometriosis. Um If you're struggling to work out what you're looking at that is very typical of endometriosis in a similar way to cancer. It kind of tethers tissues together and obliterates spaces. So what you've got there is the uterus is kind of in the middle, pointing forward. So you can see the round ligaments coming off on the, the right side of the picture and the fallopian tube on the left and then you've got an ovary just on the left hand side, which is the, the right, a bit and then the rectum is pulled forward and is stuck to the core of the uterus So the pouch of Douglas there has been completely obliterated by the presence of endometriosis. So that's what it looks like. How do we go about identifying it? Um Now, most of this I'm hoping will not be new information. Um but the fact that it's still taking a long time for people to get a diagnosis of endometriosis suggests that this is something that is worth having at home to people. So, the most common in initial feature of endometriosis is cycle pelvic pain. Um So this is pain. Um normally during the period, typically, it starts a day or two before the period starts. Gets, is a absolute worse on the first couple of days and then gets better as the period finishes. Um over time that can evolve into chronic pelvic pain and chronic pelvic pain is pain, the pelvis lasting for more than six months, but it's not associated purely with menstruation or pregnancy or any other pathology that might be there. Um And the reason that you evolve from cyclical pain to chronic pain is that you get this chronic inflammatory reaction, um which causes us problems because even if we treat and it better cause the endometriosis, we don't necessarily remove the ongoing pain that they get and can sometimes make it worse, deep dyspareunia. So, dyspareunia is pain during sex. Um and typically, if you've got endometriosis around the pelvis or big ovarian cysts, um then that would cause a deep dyspareunia which is pain within pelvis, within the abdomen or exception, intercourse. Um, whenever you've got deep dyspareunia or pelvic pain that can then progress onto superficial dyspareunia, um, which is pain typically on the outside. Um, and one of the causes for that is you can get something called vaginismus, which is testing of the muscles around the vagina. And again, if you're anticipating something to be painful, you become more tense, the more tense you are, the more painful it is. And then you get into a vicious cycle and that's relatively common. Um You can get urinary symptoms. So, diurea hematuria and you may hear people um say that every time they have a period they get a uti. Um and to be fair, you know, if you're a young woman and you go to a GP with symptoms of a UTI, they are advised to treat you for a UTI and not look too much into it. Um And obviously, if you do have endometriosis there, then you'll take your antibiotics for three days and once your period finish, as you finish your antibiotics, your symptoms will get better. Um But if you do have some surgical symptoms of a uti, I, you need to think is it actually a uti or is it something else? Um, dyschesia hematochezia. So that pertains to painful defecation, um which is more likely what you'll see. Um But hematochezia is blood in the stool which you may or may not see depending on where the lesions are. Again, you really only get that if you've got deep infiltrating endometriosis that's bleeding into the, the rectal canal, um, during your period. Um, there is a significant overlap with inflammatory anti inflammatory bowel disease, irritable bowel syndrome. Um, and again, a lot of the time if we don't find endometriosis, what we find is more evidence of a sort of a functional bowel disorder. Um, and there's a significant overlap there in terms of those populations, heavy periods are possible. Although that's more associated with adenomyosis, I'm not going to talk much about adenomyosis today um because it is slightly different. Um but also management is very similar. Um And adenomyosis is where there's endometrial issue within the myometrium. So, within the muscle of the uterus and that is also very difficult to manage and then some fertility. So, um sub fertility is defined as um someone who is otherwise well not getting pregnant after a year of regular sexual intercourse. Um within the middle population. Endometriosis affects about one in 10 women within the infertile population. Going through fertility treatments between a quarter and a half of women will have co and endometriosis. So there's a big problem there and then you may get extra abdominal symptoms, which I've put in small bracketed letters because I have literally never seen. That's all I do know that it's happened. And so you do get women getting cyclical hemothorax, cyclical, um hemoptysis and cyclical shortness of breath and those kind of things. Um And then what you often find is they have a C TPA trying to rule out ap and they find nodules in the pleura and or in the lungs. That's right. And the key thing is that symptoms evolve over time. So when you first present, you know, when you first start having periods, um the likelihood is that as the disease is starting, your symptoms are likely to be confined primarily to the time of your period. As the disease progresses, they will become more prolonged, you might have constant pain that's worse during your period rather than pain that goes away. Um Like I say, if you've got a deep dyspareunia that may develop into superficial dyspareunia, your mental health can be affected, um can then make people's um experience of pain worse, can make sexual dysfunction worse, can impact on their ability to work. Um And it generally gets worse over time. Um So one of the key things, early diagnosis as with all of these things is key in getting treatment and it can help to manage and prevent progression. So you need to these women, um you can, um and the advice is to offer it, um certainly an abdominal palpation. Now, again, if you've got someone with abdominal pain, particularly if it's the first presentation, you need to think about what else could be going on. Um Yes, it could be gynecological. Yes, it could be endometriosis, but it could also be coincidental. It could be a cyst, it could be bowel issues, it could be an appendicitis, it could be urinary tracts, whatever. Um So as part of your initial assessment of the patient, it's worth thinking about differentials and trying to rule those through with the examination. Um again, you can offer a pelvic examination, but that may not always be suitable. Um So, you know, if you've got someone who's 1415, I probably wouldn't be offering a pelvic examination for those people. Um Likewise, if you've got somebody who's got really severe pain, significant sexual dysfunction, sometimes ap examination can be really helpful, which I know sounds a bit odd, but um sometimes it does really help to address some of the underlying psychology that can be contributing to the symptoms. Um Other times, it absolutely doesn't. And again, it's something that you can offer to the patient, but you're not obliged to do. Um The other thing that's slightly irritating about this is that the examination is off you, superficial endometriosis, you might elicit pain. Um But you're not going to identify anything else. The reason to do it is to try and find a, are there any masses, are there any evidence of endometriomas? Can you do any nodules? So, a big sort of positive of endometriosis UACR ligaments, for example, you can feel that um I've been told you can feel it, but I've never known you felt um, you can also look for things like reduced organ mobility. So, if you've had prolonged chronic inflammation without successful treatment, then eventually you'll get fibrosis, which leads to your organ getting fixed, um, which then makes surgery much more difficult if we're going to try and do that. Um, and massively increases the risk of bowel, um, and urinary tract injury during surgery, investigation wise, there is no definitive investigation. Um, the mainstay now or certainly first line again, you're not obliged to do anything if you've got a young person who has got cyclical pain, um, you are and no sort of suspicion of ovarian pathology or anything like this, there's no um, mandated requirement to do any form of imaging. Um If you're thinking of doing surgery, it's always worth doing imaging. We like to have imaging before we operate on people. So they have a rough idea of what we're going to find when we get in. Um, but if you've got someone who, like I say, who's young and otherwise you don't necessarily gain anything by doing it. Um, the modality of choice as always, gynecology is a transvaginal ultrasound scan. Now again, if you've got somebody who's very young and a lot of pain, then that may not be suitable. Um So again, doing an abdominal ultrasound scan is acceptable, but you are not going to get the same level of detail. Um And we can talk about that more about why that is later if you wish. Um Why are you doing that? Well, because on a vaginal scan, you can obviously look at the ovaries. You can see whether there is an ovarian cyst endometrioma. But you can also see deep infiltrating endometriosis deposits. So you can see if it's on the bladder, if it's on the bowel, if it's around the uterus, you can also see adensis at the same time. The key thing is to tell them that you're looking for endometriosis. Um And the other issue that we've got at the moment is ultrasound is very user dependent. Um And if you're in a hospital, there is not a tertiary center for endometriosis, they may not have the skills and expertise and experience to pick it up. And so you are much more likely to get false negative results if you're in the small D GH in the countryside than you are. If you're in a big tertiary center with an endometriosis center attached MRI scans are second line as always because they take ages, they're expensive. Um They're not pleasant. Um And again, they are good at detecting ovarian endometrioma and a deep endometriosis. Um often if we do an ultrasound scan and there's a suspicion we might want more detail by doing an MRI scan. Um But the study suggests a particular benefit to one over the other, which is why ultrasound scan is recommended. First, negative imaging is very common. Um And one of the things that's key is if you have a normal ultrasound scan, that does not rule out endometriosis, you can rule out ovarian endometriosis um but you cannot rule out superficial. Most women will have superficial endometriosis which you will not see. Um And like I be recommended prior to surgery. So this is just a picture of what a classical endometrium looks like on ultrasound scan. So this is a transvaginal scan. You can tell that because of the shape of the probes at the top of the image, um that sort of semicircle shape at the top um is typical of the transvaginal ultrasound probe and you get a much wider view. And so it looks more like this then more like that. Um And the ovary is the sort of the gray lob in the middle. Um maybe because it's full of blood essentially. So blood um and clotted blood have a similar density to it to things like muscle. Um So it looks very similar to the surrounding soft tissue. The black bit behind is fluid or space um in the punch of Douglas there. And that's very typical. It's got what's often described as a ground glass appearance. Now, I'm sure, you know, you would have heard lots of things described as having a ground glass like appearance. I'm not entirely sure what ground glass is. Um But if you see ground glass appearance of an ovarian cyst in an exam question or something like that, the chances are that what they're talking about is an endometrioma. Um, if they look like this, that is very reassuring that it's not cancer. So if you have someone with ground like appearance in their ovarian cysts, or if they say it looks like an endometrioma, it is almost always benign. So you can reassure patients about that as well. So the final step of diagnosis is surgery. Um, now when I was a student, um back in 2014, um diagnostic laparoscopy was the gold standard for diagnosis. And in a sense, it still is. Um the only way that you can get a definitive diagnosis of endometriosis is by seeing it, removing it and sending the samples off to the lab to be looked at. So with that being the case, why is it our second line option? Well, firstly, because it's not 100%. So it's again, it's quite user dependent. If you have a laparoscopy by someone who's an endometriosis specialist, they are more likely to say endometriosis than someone who is. No. That's because there truly is more endometriosis there or whether because we have brought prime to look for it. I don't know. Um But either way it's not 100% unless you've taken a biopsy. Um, there's also the risk of surgery itself. So again, things like injury to the bowel, major blood vessels. Um I know in our local trusts we've had two or three major vascular incidents during the last five years, which doesn't sound like a lot. But if you're doing a lot of laparoscopies over the country, that's a lot of people. Um, having major, um, visceral injuries leading to a big midline laparotomy and exploratory surgery, which is not ideal. Um, there's a small chance of death whenever we do surgery. About one in 10,000, 1 in 12,000 people having a diagnostic colonoscopy will die. And again, if 10% of women have that, that's a lot of people. Um So by avoiding that risk, um we will hopefully be doing more benefit um to more people. Um The other issue with it is um what I'm trying to say, oh, no, come back to me. So when do we do surgery? Um We do it. If you've tried empirical treatment, which we'll come on to if that hasn't worked, then you can do surgery as a second line test. Um If the patient doesn't want to try treatment until they've got an answer, that's absolutely fine. Um Like I said, if you've had imaging suggestive of some kind of ovarian cyst, um then that would be helpful and you can again offer surgery then to confirm what the cyst is like. Um And I've already mentioned about biopsy being the only way to diagnose endometriosis. The other point that I wanted to mention was about um the actual rate of diagnosis. So, in our local tertiary center in Sheffield, um our in the endometriosis service. They're a tertiary referral center for patients with complex endometriosis. In theory, in that service, one in three diagnostic laparoscopies were negative. So the rate of a negative laparoscopy is between 30 50% depending on where you are. Um And that's the other reason because if half of the laparoscopies that you're doing are not going to find endometriosis, then you're not doing those people any favors. Um And we'll come on into more issues with surgery a bit later. Quick word about staging. Um The most common staging technique that's used is the A SRM or the American Society of Reproductive Medicine which separates it into minimal, mild, moderate and severe. Um For me, that's pointless. You might hear people talking about using those technologies. The only reason I included it here, but there is no relationship between the stage of disease and the patient's symptoms. And there is also no relationship between fertility and the stage of disease either. So, what the current advice and what I would suggest is that you just describe what you see and where you see it. So normally when you're doing a diagnostic laparoscopy, what you do is you list all of the common areas. So the bladder, the uterus, open tubes, ovaries, foss, the ovaries, pouch, Douglas, bowel, diaphragm, whatever. And you put water endometriosis, yes or no. And if there was what was it? Um and just be descriptive, it takes longer, but it is more useful, like with a lot of things. And that I think is an interesting point in general that, um, the degree of endometriosis has no relationship whatsoever with the pain symptoms. So, um, I've seen a, a lady in Barnsley. Um, so Doncaster who had horrible endometriosis on an MRI scan, she had bilateral endometriomas. She had deep infiltrating endometriosis in the bowel. Her uterus was completely stuck to the bowel wall. It looked terrible. Um, and she had barely any symptoms whatsoever. So she didn't want surgery. That's completely fine. Um, she didn't even want medical management. She was completely fine as she didn't want anything. Um, or you may have someone who's got really severe pain and you find one tiny speck that could well be endometriosis and you treat that and then hope for the best. Um, so while on the one hand, trying to get staging, trying to define where it is what you're seeing. Um, where the lesions are can be really helpful. Um, it doesn't necessarily correlate with what the patient's seeing and it's not uncommon that patient reports severe left sided pain. Um, and we actually see on ultrasound scan, a right sided cyst that's completely incidental, um, which makes this very challenging. So how do we manage and traces same principles? Anything within gynae broadly speaking, you will have conservative medical and surgical options and there is always an MDT love, an MDT. Conservative management do nothing. Basically. Um, I would possibly include things like mental health support and physiotherapy in this. Um because you're not doing anything to modify the disease as such, but there is always an option to do nothing. And if that's what the patient wants, that's fine. Although I would question when they come to see you in the first place, medical treatments is broadly divided into hormonal and nonhormonal. We'll come back to that surgical treatments again, it is something that is done a lot, um has, is quite controversial and batten a little bit as well. Cyclists will support um is really important. Um So again, if just logically, if you've got someone with chronic pain that is going to make you miserable, and if you are miserable, if you develop depression, your perception of pain will be worse. Um If you're depressed, you won't sleep, which will also make your pain worse. So, the aim of the psychological support is to try and break the link between their mental health and their pain. Um And also to try and improve the mental health in general because if they're depressed, um that will make them feel worse and that is something that we can correct. So it's quite important not to forget physiotherapy. Um again, is very common if you're someone who's in pain, um and often you end up with significant muscle tension. Now, again, if you think about if some, if you're expecting someone to hit you or someone's throwing a ball at you or, you know, you're about to have a car crash or whatever you tense, you tense your muscles to brace for that impact. Um And the same thing is true when you're in chronic pain. So people are often have really significant tension in the paraspinal muscles of the pelvic floor, abdominal wall of, of the upper legs. Um And what the physiotherapists are, are quite good at doing is identifying sort of trigger points or points of tension and helping to release that. Um And by moving that again, you're not treating the underlying disease, but you might improve their symptoms and find you've got sort of chronic paintings and the availability of these varies depending on where you are and is run by different people, depending on where you are in my current trust. They are run by an anesthetists, um who are very good at managing sort of physical and neuropathic type pain. Um And much more experts at dealing with things like um the neuropathic medications, drugs, like local anesthetic injections. If they find a particular nerve that's particularly flamed, you can anesthetize those. Um and they can do a lot of quite clever stuff there. And they also have quite good access to doctors for physical therapy and all the rest of it. So if you start off looking a little bit more about medical treatment, so again, n does say you can use paracetamol and anti-inflammatories. Um fine, I would expect most people have really tried that if they have tried that, they test it because it just on people, um, nonsteroidal antiinflammatories. Um, I don't know if you're still getting talks about methylic acid being a good anti-inflammatory. It is no more effective than ibuprofen. Um, and is only available on prescription. So, if you have someone who's got pain, ibuprofen is fine, um, and it's as effective point about opiate solicitor for all chronic pain. I'm sure you are all aware of what's happening in the United States and their opiate crisis at the moment that was caused by people prescribing oxyCODONE and other opiates for long term chronic pain. As we all know, if you use opiates regularly for a short period of time, you become addicted to them and if you for a long period of time, you become very addicted to them. Um it causes all kinds of other problems. So, opiates are acceptable for use in acute pain in this context. Again, cancer, these separately just for this, specifically, um opiates are fine for acute flares. So if you've got somebody who's in the hospital, someone who's COVID at all with the pain, then by all means use opiates in acute phase but do not continue it because again, it takes less than a week to become dependent on opiates and then you are stuck. Um It can also cause constipation. And if someone, if there's a red element of something like ibs in the background, there and causing more constipation is only going to make the pain worse, which is silly. Um, neuropathic pain. So, neuropathic pain is typically described as burning, shooting electric shocks, that kind of thing. Um And again, you sometimes see that particularly after surgery irritatingly. Um, and there, there's a range of options, things like amitriptyline, prega gabapentin, DULoxetine, um, which are all new modulators. And the idea of these is that they reduce the input from those nerves going to the brain. Um Some of them work fantastically. Some of them don't. There's always an element of trial and error if it doesn't work it as with all of these things, if you get no benefit, stop using it. Um And like I've said, you may want to consider a referral to a pain specialist for it. If you're a GP as well, you can do that and you don't need to see gynecology just to get access to chronic pain or treatment. Now, this is the mainstay. This is a lot of what we do day to day. So what the point is primarily to stop pain? How does it stop the pain? It stops the pain by stopping your periods. The idea being that if you are no longer bleeding, then you are no longer releasing blood into your peritoneum, which is no longer cause of the pain causing the inflation. Um We think it might also stop the progression of the disease. Endometriosis is a chronic progressive disease. So the longer you have it, the more deposits you tend to get. Um So the aim of this is to arrest that progression. If possible, it doesn't always work, but sometimes it does. Um, and it can also stop the progression to complex pain. So if you have someone who's got um uh surgical pain and you stop the pain early on in its course, you are more likely to prevent them going on to develop long term chronic pain, which is then much more difficult to manage. Um, you may delay the need for surgery. Um, and that's always a good thing. You know, if you, uh, it's not uncommon to, to see someone who's 1516 with pain, you give them a combined pill, their periods stop, the pain goes away. You don't need to do anything else. Um, and hopefully, you know what I put in bold is improve quality of life. That's the whole point here. You know, endometriosis is not in itself a life threatening disease. It's life really life altering, but it's not life threatening. So, everything that we're trying to do is trying to make the woman in front of you feel better and if you're doing something that makes her feel worse, then stop doing that. Um, and like I've said, if the, that you're using is working, don't ask too many questions. You don't need to investigate. You don't need to refer, you don't need to do anything else. If you start them on the mini pill, the combined pill and the symptoms go away. Take that as a win and let them to it. So nice recommends first line if you've got a young otherwise well person, you know, all the usual caveats of a combined pill um with symptoms of endometriosis offer them something hormonal. Normally the combined pill and the reason for the combined pill is that it works by stopping ovulation. If you stop ovulation, you completely suppress the menstrual cycle and you should therefore completely stop the development of any endometrial tissue anywhere in the body. The mini pill, things like the progesterone only pill are acceptable alternatives if they're not able to take the combined pill, if it doesn't work for them. Um The problem with the mini pill is that it doesn't always stop population. The only one that does semi reliably is desogestrel. Um The rest of them don't necessarily. So, um that's why they're not necessarily your first choice, although we do use them a lot and they can be very effective in terms of stopping bleeding. Um One thing that is important whenever you're using pills, um and this always amazes me is the number of people who were told to take it like it's contraception. Um We're not using it for conception here. The contraception is a benefit, it's a bonus. Um But you're using it primarily to stop pain symptoms. And if you're someone who gets pain when you're bleeding and you're told to have a pill free week, you're just inflicting pain on them for no reason. Um So just run the pill back to back. There's no harm in running the pill back to back. There's no benefit in having a pill free break. Um What I would tend to say to people is if you run it back to back and back to back and back to back, eventually, you will start getting breakthrough bleeding. At which point at that point I would have a break for a week and everything to reset itself and then go back to running it back to back. And if you've got no breakthrough bleeding, just keep running. It don't stop. Um, because otherwise you're gonna get pain and that's silly. Um, other things that are effective. So, er, the implants depo Provera or Cyano, which is similar, um, the Mirena coil are all appropriate. Um, and again, it's patient choice. So again, if you're 16, you're probably not going on to Mirena, but you may be happy with the depo or an implant, you know, it's up to you what you want. Um, the Mirena has technically the best evidence to support it in terms of symptom um, improvement. Um, but as always nature of how having, having a coil fitted, um, means that it's not always a popular choice, particularly if you've got someone who's already in pain. Um, one thing that is an option is if we're doing a diagnostic arthroscopy for these people who get fit to mire and coil at the same time so that they don't have the, the, the difficulties of it being fitted, but they do get a benefit from it. G NH analogs, a cell line. Um G NH analogs are gonadotrope inducing hormone analogs and use those to induce an artificial menopause essentially. Um With the idea being that when you're menopausal, um your menstrual cycle is stopped and therefore any endometrium that's there will regress. Um The problem with them um is that they cause significant side effects in terms of menopausal side effects. So the most common things would be things like hot flushes, night sweats or sleep. Um You might get a brain fog, um worsening of depression symptoms, those kind of things. Um as well as the long term physical side effects of being menopause such as reduced bone mineral density, cardiovascular disease, um risk of stroke, those kinds of things. Um So in younger women under the age 4550 we should be giving them H RT um to protect them from that. Um But it is very effective and, you know, you'll have seen the GNR H A license for up to six months, I think. Um in practice, we use them for years. Um and we have women who've been on them for 3456 years, symptoms, well controlled H RT is managing the menopausal symptoms and they're absolutely fine. And if they're happy with that, that's absolutely fine. Now, one thing you might have noticed about all these, that these are all conceptions all make you menopausal. And so if you are wanting to get pregnant, that is an issue. Surgery. Now, surgery is hugely controversial. Lots of people. Um, the expectation is that surgery is the answer. Um, and I'm here to try and persuade you that surgery may not always be the answer. Um So the first thing to say is there is a, a an incredibly depressing lack of good quality evidence to support surgery and endet. Um Most of the research that is done again from a surgical perspective, superficial endometriosis is not interesting, is interesting, is deep endometrial bowel resections, it resecting the bladder, it's resecting the ureter, it's affecting the diaphragm, complicated surgery. So we have done more studies looking at that and have more data looking at that than we do for the superficial endometriosis that affects the vast majority of our patient population. So there is um very limited information to support its use. Um There is no information beyond about 12 months. Um Now again, this is a chronic, long term incurable condition. Um And so if you're 19 and you have surgery when you get to the age of 20 we will no longer know what the outcomes are going to be, which is nonsense. Um I'll come back to that in a second. Um We haven't really got any good information about fertility, which again, I come back to um we know that surgery of any description improves pain in the short term, whether it's diagnostic or operative laparoscopy, I'll come on to our operative in a moment. Um Operative laparoscopy probably has a bigger impact in the short term, but we also know that operative laparoscopy has more chance of a deterioration of chronic pain in the long term, which is shown by high rates of repeated surgery. So, more than 50% of women with endometriosis who have an operation or have another operation within five years. Um And in a significant portion of the time, you don't necessarily find any recurrence of endometriosis. Chronic surgical pain is a real issue as well. Um Now I was always quoted, around 10% of women will have of not women, 20% of people having surgery with chronic pain, um after surgery. And that's true. So that's why you get things like phantom limb pain. Um, because you know, when you're having a general anesthetic, the nerves are still registering that you're in pain, your brain isn't registering it, but the nerves in the region are. And so that signal gets upregulated and up regulated and up regulated to a point where any stimulus is then perceived as pain. So for endometriosis patients, they are already in chronic pain and a deep endometriosis is about 5% compared to superficial, which is about 80 And so if you've already got a chronic pain, your nerves are likely to be already slightly sensitized to pain, you're more prone to recognize pain. Um, and then if we then do surgery in that area that is only going to upregulate that symptom more. Um, so the rates of chronic post surgical pain can be 30 40% depending on the type of surgery that you're doing. We've already mentioned the complications of surgery. So, like I say, injuries to the bladder, the bowel, the IVC and the AORTA death, negative laparoscopy, um, open surgery. All of these things are possible. Um And yeah, up to heart laparoscopies are negative for women. We are trying to conceive. Um, that is very controversial. Um And we will come back to that. Um And the answer is there are no good options, surgical treatment. Um So for a variant and deep infiltrating endometriosis, like I say, you're more interested in this, the surgery is more interesting. Um, if you're into that kind of thing. So there is evidence to support surgery. It's not great, but there is some, um, deep filtrating endometriosis should be managed at a tertiary endometriosis center. Um, because you are doing visceral resection, you are not just treating the peritoneum, you are um, operating on the ureters on the bowel on the bladder. Um, so there are a very small number of gynecologists who are trained to do that. Um, superficial endometriosis, as I've said, is more controversial, it may improve pain in the short term. Um But at the moment because of the lack of evidence, um there is a multicenter randomized controlled trial called Aspirate Two happening at the moment around the UK um which has been run by the University of Edinburgh um in South Yorkshire Barnsley are currently recruiting. Um I am in the process of setting it up, Doncaster as well and I'm hoping to start recruiting next month. Um with the idea being that we're randomizing people to diagnostic or operative laparoscopy, so that we can see whether there's any long term benefit in terms of superficial endometriosis. Um And again, you don't need to know too much about this. If you've got an ovarian cyst, the treatment surgically is an ovarian cystectomy. Um So you remove the cyst and try and leave the ovary b deep infiltrating endometriosis. Don't worry too much about that. You just try and remove as much of the endometriosis as you can without damaging the underlying organ. Often we end up needing to do bowel resections, resections, taking out chunks of the bladder, sort of ureteric, re taking out a bit of the ureter and re anastos, it's all very complicated. Um So you don't need to worry too much about that in terms of superficial endometriosis, there are three broad techniques. Um One of which is using a laser. So in Sheffield in Doncaster, I think in Rotherham as well, they use a laser called helia, um which has a very, very superficial, um, laser burn to the peritoneum. With the idea being that it destroys the superficial endometriosis without causing deep tissue damage. If you don't have access to that, then the traditional treatment was with diathermy and that is literally setting fire to the peritoneum. Um Having seen that done, it is not at all surprising that these women's pain is worse. Um And I have had patients come back to me after having diathermy treatment for their endometriosis saying they can feel the burning, they can feel the knife, they can feel the cutting. Um And that is because that is literally what they're feeling. The nerves are so sensitized to what's happening that the bowel moves over them as the ovaries move, you know, whatever is happening inside the abdomen, they are feeling it like they are on fire. What do you do with that? Difficult, difficult? Um The third option is resection. So, um like I've mentioned, the only way to 100% guarantee that you've got a diagnosis is to take a biopsy. So the way that we do that is normally using um sort of a monopolar like a pencil diathermy device to resect a small area peritoneum. Normally, some, it's not particularly important. Um So we wouldn't do it over the ureter, but we might do it over the sacral ligament, for example. Um And send it off to the lab to be looked at now again, in Sheffield, in the tertiary centers, they like to do that. They like to get a tissue diagnosis in other places. It's more surgeon dependent. Um But I think that's becoming more common. Um because we'd like to have a definitive answer rather than just relying on pictures. We all like biopsies as surgeons. We love biopsies, hysterectomy. Um So you can offer a hysterectomy. Um I, in my experience, I don't find it always a very good option. Um What you have to do, you have to take away the whole uterus. So you take away the uterus cervix, the uterus cervix, fallopian tubes, you can leave the ovaries, although if they have ongoing ovarian issue, if there is any endometriosis left after surgery, that will continue to propagate. And so they may need ongoing hormonal treatment regardless. Um And the idea being that if you remove the uterus and remove any endometrial deposits that you can see, um, then that in theory should remove the cause, um, and remove the cause of the symptoms. Um Does it work? Not really. Um I think if you've got someone who's, you know, really, really suffering and they want everything removed, you know, it's not unreasonable. Um, but rates of chronic pain are very high. Um I remember I was a, an ST one, in Rotherham a few years ago we had a, a lady who'd, um, by the book of the notes, she almost bullied the consultant into doing hysterectomy and she'd come back six weeks later with severe pelvic pain and that was just her chronic pain. Um, the pain was very similar to that, that she's had before surgery. She thought it would get better. It didn't. And she's now left where we've removed all of her pelvic organs. Um, but she's left with the same chronic pain that she had before, if slightly worse because of the nature of the surgery that she's had. So patients need to be aware of that. One of the things we do sometimes offer is say, look, let's give you a G NRA analog. Let's see what happens if we switch off your system. If we shut down your ovaries, shut down your uterus, make you postmenopausal. If your symptoms get better, then a hysterectomy might help if it doesn't, then a hysterectomy is unlikely to make a massive difference. And that can be quite helpful in decision making, not guaranteed, of course, but it can be helpful. What I think is becoming clear is that the management of this is not easy. Um, other things, a physio we've spoken about briefly, skip over that psychology again. It's something that if you say, if you say to someone, I think you need to see a psychiatrist. People often bristle or get quite cross, which is fair enough cos what people hear when you say that is that you're nuts. Um, I don't think you're in pain. I think that you're insane and therefore you need to see, um, an insane person doctor to make you better. Um, it's really important to make clear that that's not what's happening. So when I see people in clinic, what I would often say to them is that, you know, what, what impact this is having on their life, what impact it is having on their work on their relationship, you know, with family, with their partner, with their kids, whatever. Um What is their view of themselves that your body can be really severely affected? Um And just look for any symptoms of depression and sleep is another really important one, poor sleep is often a really good sign of, of, of deteriorating mental health. Um um So if you say to them that look, you've been in pain for a long time, if you're in pain for a long time, that can make you depressed, it can have a really negative impact on your, on your wellbeing in general. Um And by focusing a little bit on your, on your sort of your psychological wellbeing, um we can make you feel better in yourself, may also improve your pain a little bit in the way that you experience it. Um Which is what I mean by pain tolerance. So we're not improving your sort of resistance to pain. What we're doing is you're reducing the amount of attention that you're giving to that pain, giving it less of a of a, of a, of a focus in life and it's very common for people who've had long term symptoms that their identity is wrapped up in their suffering. Um So you'll often see, you know, people with fibromyalgia, people with um me, people with endo. Um it's often a big part of who they are, they identify themselves in the same way that as doctors being a doctor is quite a part of your identity. Um So, trying to sort of break that and make it down someone with endometriosis rather than someone defined by endometriosis is quite important, psychosexual therapy. Again, if they've got sexual dysfunction, um if it's interfering with their relationships, that kind of thing, then again, that's quite important and it can be really beneficial. And again, most of these, most of our patients are young. Um and it should be, you know, having a, having a healthy sex life is part of, it should be a normal part of chronic pain team you've mentioned and they do all kinds of ways they are going to get into a fertility. Speaking of fertility, um this is something from, if you're being purely mercenary about things, you do not need to know this, this is something that is complex and controversial for my level. Um So for, for undergraduate level, you need to know there's an issue. Um But the actual management of it is controversial. Um So this is purely for interest. So as I've mentioned, endometriosis affects one in 10 women of reproductive age. There's about more than a half of women in the UK, rises to about 25 to 50% of those with subfertility. Now bear in mind that subfertility around in a year depending on your age, between 85 and 90% of people will be pregnant after a year rising to between 90 to 95% in two years. Um So around 110 will have some form of some fertility, but in your twenties, your chances are lower. So about percent when you're in your late thirties, your chance rises to 15 to 20%. So there is an age gradient there as well. Um Now, the mainstay of management, as we've said, um is long term hormonal treatments, contraceptives, GNRH, which is not ideal if you're trying to get pregnant. Um So that is a difficult position if you've got someone who's trying to get pregnant. Sort of that counseling is really, really challenging. Now, what does endometriosis actually do? How does it work? Well, dyspareunia, I work around this circle. Dysfun, obviously, if having sex hurts, you're going to want to do it less and not for too fine a point in it. But if you're not having sex, you're not gonna get pregnant. Um scarring fibrosis. So if you have a chronic inflammatory or any inflammatory condition within the pelvi, it can distort the anatomy. So if you have appendicitis, pelvic inflammatory disease you can damage the tubs which can cause dysfunction and reduce the chance of getting pregnant, endometriosis. The inflammation can damage the eggs as it gets released into the. Um uh it can cause damage just by the nature of the inflammation and the inflammation around the endometrium can have some impact on the immune cell population that live there. And again, you don't know too much about this, but the way the facet embeds itself is a complex relationship between the trophoblast and immune cells, specifically natural killer cells within the uterus. Um And if you have a sort of a large lymphocytic or neutrophilic population within it that can disrupt that process. Um Pelvic surgery, again, for the same reasons, we can damage your um broken tubes, we can damage your ovaries and cause problems there and then issues with the ovarian reserve. Ok. Interestingly, for superficial endometriosis, having surgical treatment may I emphasize may improve spontaneous pregnancy rates. So the there is an option. If you are someone who is trying to get preg or wanting to get pregnant, then surgical surgical treatment is an option and may be effective. And again, you will get some benefit in terms of short term pain relief and it may improve your chances of a spontaneous pregnancy. That is not a bad option. Um Surgery for ovarian deep endometriosis and this is perverse as I would have assumed would be the opposite. But anyway, there is no evidence that surgery for ovarian or deep endometriosis has a positive impact on your fertility. It doesn't have a negative impact. So, if you're going to do it for other reasons, that's fine. Um But the devices do not offer surgery in um ovarian or deep endometriosis purely for fertility improvement. If you're going to do it for symptoms, that's fine. Um But it, there's no evidence that it improves your fertility. Um Often in these cases, IVF is going to offer the best chance of a pregnancy. Um So, rather than not doing surgery, and again, this is where you need to liaise with your fertility specialist. Um They may want to say if there's a big ovarian endometrioma that gets in the way of the collection at IV, um then they may want surgery for that reason. And but if they don't think it's gonna be a problem, you don't have to operate um an interesting post surgical medical suppression though using 3 to 6 months of the Mirena progens and GNRH may improve fertility rates afterwards. And a trend towards that, although it wasn't statistically significant presurgical hormone treatment does not interestingly don't know why little points for endometriomas. So, endometriomas um gradually destroy follicular tissues. The ovary, the functional unit of the ovary is the primordial follicle. The primordial follicle is an egg surrounded by supporting cells. Um You're born with about a million, by the time you go into puberty you have about 400,000. And when you run out, you go through the menopause, essentially. Um If you have a big bleedings on your ovary, you will gradually destroy that tissue, destroy those follicles. Um And so cyst in themselves can have an impact on your ovarian reserve, however, surgery or will cause damage to the surrounding tissue. Um So if you have bilateral endometriomas and bilateral endometriomas are common, about a third of people with one will have two. then the chance of putting someone into the premature menopause at some point after their surgery is about 2%. So that's quite a lot. Um or quite a high risk really considering um they have high recurrence rates as well. So again, if you're going to re remove that cyst, that's fine, but they need to know it might recur, they need to know it's going to affect their ovary reserve. They need to know it's not going to possibly impact their fertility. Um They need to know it's likely to come back and all of which um it's not great. Um The other problem with endometrium is it has a reduced response to fertility medication. Now, again, removing it does not improve that because um the way that fertility treatment works is you're getting a number of those follicles that could potentially ovulate and you're making them all develop rather than just one. So if you destroyed a whole load of them by doing surgery, you're gonna have a smaller pool of of egg, of eggs available to choose on essentially. So people often need much higher doses and have a much worse response in IVF the pregnancy rate is similar. Um but overall the more eggs you get, the more embryos you're gonna get, the more embryos you're gonna get, the more likely you are to have a successful pregnancy. It's a numbers game. Unfortunately, that's particularly true. You get, once you're over 40 the chances of a successful pregnancy in this context, a very light, very light. So in summary, the people in the news who were not told they had endometriosis for 11 years, that shouldn't happen, it shouldn't happen because we know what the symptoms are. The diagnosis is primarily clinical. It can be made in primary care treatment can be initiated in primary care and if their symptoms improve with empirical treatment, that is it, you have done your job. Um it can slow disease, depression, it should improve their symptoms. Um You can do imaging but you should do imaging really. Um particularly if you're planning on surgery. Um and surgery is second line. So you asking you what the gold standard is later, there is no longer a gold standard. Essentially everything is a little bit. Um Treatment is targeted at the patient's symptoms and quality of life and that's true to save up in gynecology. You need to find out what is what the patient's primary concerns are and try and address those specifically rather than going from your agenda. Remember there is MDT and again, in in medical school exams, I, when I was a medical student, there were questions about name seven members of the MDT involved in the care of someone with s um So they do like to ask me questions about that and there's a lot of people involved in the care of these women. Um And fertility is a big concern for people and it is very, very difficult to manage and there's very little evidence to support doing anything. Um Let alone anything positive to go on. That's what I have to say. Did anybody have any questions? Do you want me to pop it in the chart? Um It's not common, I would say um but we do see it, I think the, the pathophysiology. So, um after a Cesarean section, you've obviously got a breach in the full thickness of the uterus. Um And the theory is that if you've got endometrium um exposed where it shouldn't be, then you can then see endometriosis. It's similar to the principle of the retrograde menstruation. So the bleeding through the fallopian tubs causing endometriosis. Um One of the reasons we do a two layer closure. Um So when we do a Cesarean section, you close the incision that you've made with one layer and then you suture a second layer over the top to try and bury that first layer. One of the reasons to do that is try and reduce the rates of cesarean scar endometriosis. Um doesn't work. No idea. Might do, makes us all feel a bit better. Um, but you can also create little pockets and niches people. You know what we, what I see more than um endometriosis. Um, or I have seen more than CS scar, endometriosis. Um, things like sea scar niches where you have a little pocket of endometrium. Um But then every time you have a period bleeds into that pocket and that pocket gets gradually bigger and that ends in the same way, severe cyclical pelvic pain. Um And the treatment for that again is either you stop them from having periods or you do a hysteroscopy and resect. Um that niche, some people end up needing the cesarean scar revised. And so you go in and do laparoscopic. So the removal of the front wall of the uterus and then repair it. Um But that again, is complicated and not, not, not something that's commonly done. Um That's all right. So I think I know everything looks a bit doom and gloom on there. One thing I would say is that we do get, once we find the right regime, we can often have a really good impact, um particularly if people are younger. Um And as with all of these things, early diagnosis, early treatment is key. Um So, you know, if you're someone who's 40 you've had pain for years, there's very little we're going to be able to do at that point, it's just really difficult and, and so the earlier you get in the better. Um, and you can, you know, it's very, you know, most of the patients, um we get a lot of students referred to, um, you speak to them, you start them on the pill, six months later, they're completely pain free and you go, that's great. Carry on, do what you were doing. Um I don't know too much about it. Um Yeah, we do have a, we do have a good positive impact. Um The problem is we haven't collected the evidence. And so the big issue that we've got really treat with a lot of gynecology is just getting an evidence base to back up what we think. So what we think we're doing is correct rather than being quite sur and focused to which most of the research has been previously. Thanks. Um Yeah. If anyone's got any questions any more questions, please feel free to pop them in the chart. Ok. You can always email me as well. I take mine. Ok. Um If there's no more questions then um Yeah, thank you so much, Jamie. It's been really, really helpful. Um And really, really interesting as well. There is um if you want to learn more about what we should be doing, there is a nice guideline in the diagnosis and management of endometriosis. And if you're more interested and more of a of Punishment. Um The European Society of Reproduction PS um has got a really good guideline that we actually follow more closely than I. Um So again, if you are really interest, that's the one to have a look at. Um but II warn you, which is quite dense. So, um you know, I might be easier and it's probably, you know, from an exam perspective, we will go from ice. Mm OK. Um Yeah, that's great. Thank you so much Jamie. Um and yeah, as I said, um if everyone could just fill in the feedback forms at the end as well, um it should have been emailed to you or you'll just get it at the end of the session. Um and then you can get your certificate right after. Yeah. Thank you guys so much for joining as well. Thanks. Um Jamie. I just had a quick question about endometriosis. If that's ok. Um So in women who are on medication, then would they sort of, would you sort of expect them to be on medication long term or like for the rest of their lives or would they eventually be able to be weaned off of it? They uh get depends um normally um symptoms would stop at menopause in there. So if you get to benefit from a hormone treatment, um we would suggest so things like the my coil and, you know, the reason we love the mini coil is because it stays in for ages. Um, and it, it's got a really good success rate. So, um, as we would do for anything, you know, if you've got any bleeding, if you've got any, any sort of anything like that, then we would just leave you on your treatments until, until we expect you to be postmenopausal. So around 5055 something like that. Um, and then, and then stop it and see, um, and normally that would be the, that would do the trick. But yeah, they do. Unfortunately, you do need to run it. It's like I say, it's, it's, it's a chronic disease, it's incurable. So, um the management is something that will need to be long term. OK. Thank you. You know, if you're using a combined pill or something like that, like that sort of regular risk assessment is something that you would need to think about. Mhm. You know, from a smoking BP B and perspective. OK. Is there any sort of like, I don't know if this is a silly question but is there any sort of correlation between bad men? Mm Bad endometriosis symptoms and like bad menopausal symptoms if that makes sense? Um I don't think so. Um Like I say you are, if you've got bad endometriosis um as in objectively bad rather than subjectively bad, um then you are more likely to have early menopause and early menopause is likely to be more challenging. But again, there's no kind of, there's no strong relationship between you, um, the objective and the subjective experience of what of what people have. And then with the menopause, uh, it doesn't seem to be particularly.