PREVALENZA
DELL’ENDOMETRIOSI
Massimo Luerti
U.O. di Ostetricia Ginecologia 1
A.O. della Provincia di Lodi
[email protected]
Unità Operativa di
OSTETRICIA E
GINECOLOGIA 1
PREVALENCE AND INCIDENCE
OF ENDOMETRIOSIS
PREVALENCE
the number of people who currently have the condition
Incidence
INCIDENCE
the annual number of people who have a case of the
condition
GENERAL PROBLEMS WITH
DATA
Unclear sources
Data ranges
Different definitions of prevalence
Different sources
Different study methodologies
Different disease categories
Different years
Different locations
Different age groups
Different racial factors
Inherent reporting bias
Country-specific information
PROBLEMS WITH
PREVALENCE DATA
Diagnosed versus undiagnosed prevalence
Different methods of gathering prevalence data
Prevalence and "cured" or "remission" conditions
PROBLEMS WITH ENDOMETRIOSIS
PREVALENCE
Need for a surgical diagnosis
Atypical endometriosis
Pelvic and extrapelvic localizations
Histologic confirmation
Racial factors
Infertility
Pain
ENDOMETRIOSIS
Need for a surgical diagnosis
The only reliable way of determining its presence is
through surgery or at autopsy. Surgical incidence is
biased by the selection process bringing the patient to
the operating room. No large cadaver study examining
autopsy specimens for endometriosis has reported
data that has been widely accepted.
Eric Daiter, M.D
Atypical endometriosis
lesione tipica:
Nodulo
nero
Lesione
a
chiazza
giallo-
Lesione
cicatriziale
bruno
lesione atipica:
Lesioni
Escrescenze
rosse
bianca
a
fiamma
ghiandolari
Opacizzazioni
bianche
peritoneali
Petecchie
Aree
di
Aderenze
Aree
ipervascolarizzazione
sotto
giallo
Chiazze
giallastre
peritoneali
ovariche
brunastre
peritoneali
Atypical endometriosis
L
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8
1
6
7
8
1
5
0
4
7
PELVIC AND EXTRAPELVIC LOCALIZATIONS
ovaie
legamenti utero-sacrali
cul-de-sac
peritoneo della pelvi
setto retto-vaginale
intestino, retto e
appendice
cicatrici laparotomiche
vescica
vagina
polmone, linfonodi,
pleura, cuore, osso
PELVIC AND EXTRAPELVIC LOCALIZATIONS
Typical age range at diagnosis 20-40 years
About 10% of the cases in women under the age of 20
2-4% of postmenopausal women
In 60% of the cases, ectopic implants in the cul-de-sac
and/or the uterosacral ligaments
In 50% of the cases the ovaries are involved
In 15% of the cases the bladder is involved
In 10% of the cases fallopian tubes are involved
Extrapelvic endometriosis without genital tract implants is
rare and occurs in less than 8% of cases
Up to 20% of patients may experience endometriosis that
affects the bowel, rectum, appendix, or ureter if they have
pelvic endometriosis
Extra-abdominal endometriosis is rare
K.W. Schweppe, 1988
ENDOMETRIOSIS
Histologic confirmation
La conferma istologica varia dal 3% al
100%
Peritoneo macroscopicamente normale
può risultare sede di microfocolai di
endometriosi nel 15-25% dei casi
Racial factors
Unique ultra-orthodox Jewish population
over the past 20 years 1,434 hysterectomy specimens
reviewed
incidence of adenomyosis among the hysterectomy
specimens decreased from 15.14% in the first 10 years
to 9.24% in the second decade (p < 0.05)
the incidence of endometriosis remained unchanged,
and was very low (1.12%) compared to published data.
Asia
Oceania J Obstet Gynaecol. 1994 Jun;20(2):125-9.
Effects of heredity, religious and social behavior on the prevalence of endometriosis Bocker J, Tadmor OP, Gal M, Diamant YZ,
Racial factors
Extrapolation of Prevalence Rate of
Endometriosis to Countries and Regions
The following table attempts to extrapolate the
above prevalence rate for Endometriosis to the
populations of various countries and regions. As
discussed above, these prevalence
extrapolations for Endometriosis are only
estimates and may have limited relevance to the
actual prevalence of Endometriosis in any region
INFERTILITY
LAPAROSCOPIA DIAGNOSTICA ed INFERTILITA’
Inspieg.
16%
Miomi
14%
Fatt. Tub.
44%
Endometriosi
16%
PCO
1%
Aderenze
9%
INFERTILITY
L’incidenza dell’endometriosi è più elevata nelle donne
con sterilità rispetto alle donne fertili.
Incidenza della endometriosi nella sterilita’ ed infertilita’:
risultati del Centro di Sterilita’ di Reggio Emilia in 1011
donne sottoposte a laparoscopia di bilancio per sterilità o
infertilità *
Stadio
endometriosi
Donne
Donne
Donne
N°
%**
%***
I
158
15,6
41,9
II
103
10,2
27,4
III
60
5,9
15,9
IV
56
5,5
14,8
* Donne infertili con sospetto di utero setto o bicorne
** Riferita alle 1011 donne sterili o infertili sottoposte a laparoscopia
*** Riferita al totale delle 377 donne con endometriosi
INFERTILITY
LAPAROSCOPIA DIAGNOSTICA ed INFERTILITA’
Rilievo Laparoscopico
INDICAZ.
Sterl Insp.
INSPIEG.
%
14,3
FATT. TUB. ENDOMETR
%
%
65,7
14,3
ALTRO
%
5,7
Ster. II
14,3
57,1
14,3
14,3
Endometriosi
33,3
-
66,7
-
Fatt. Tubarico
-
90
10
-
Fatt. Maschile
-
66,7
33,3
-
Altro
-
66,7
33,3
-
INFERTILITY
LAPAROSCOPIA DIAGNOSTICA ed INFERTILITA’
Riscontro Laparoscopico nella sterilità inspiegata
Fatt. Tub.
66%
Occl. tubarica
monolat. (20%)
Alterazioni
tubariche (34%)
Occl. bil.
(12%)
Inspieg.
14%
Altro
6%
Endometriosi
14%
PAIN
DOLORE PELVICO CRONICO (CPP)
1300 donne sottoposte a LPS per CPP
nessuna lesione
40%
endometriosi
28%
aderenze
25%
Howard, 1993
Differences in the prevalence of the disease vary by
as much as 30–40 times.
Differences in the indications for laparoscopy and
laparotomy
Differing degrees of attention paid by surgeons to the
accurate identification of endometriotic lesions and by
selective mechanisms drawing patients with suspected
endometriosis towards specialized centres.
There are no published studies on representative
samples of the general population.
It is difficult to compare estimates of prevalence
because the published studies include women with
different conditions, and are conducted in centres that
apply different diagnostic criteria and exhibit different
levels of clinical interest in endometriosis.
Best Practice & Research Clinical Obstetrics and Gynaecology
Vol. 18, No. 2, pp. 177–200, 2004
ENDOMETRIOSIS:
INCIDENCE RATES
The "Public testimony to the US Senate Committee on
Labor and Human Resources, Subcommittee on Aging“
report in 1993: about 5 million women in the USA are
affected by endometriosis.
Widely used numbers for the incidence of
endometriosis include 3-10% of all reproductive age
women and 25-40% of all women with an infertility
problem.
Eric Daiter, M.D
Animal Studies in Endometriosis: A Review
Lisa Story and Stephen Kennedy
ILAR Journal, Volume 45, Number 2 2004
The exact prevalence of endometriosis in the
population cannot be ascertained because of
the need to perform an invasive procedure to
determine who is affected. Nevertheless,
estimates range from 2 to 22% in
asymptomatic women, 40 to 60% in women
with dysmenorrhea, and 20 to 30% in women
being investigated for subfertility (Farquhar
2000).
Human Reproduction, Vol. 17, No. 6, 1415-1423,
June 2002
What makes a good case–control study?
Design issues for complex traits such as endometriosis
Krina T. Zondervan1,3, Lon R. Cardon1 and Stephen H. Kennedy
Because of the need for a surgical diagnosis,
the prevalence of endometriosis in the
general population is unknown. Estimates
from asymptomatic fertile subpopulations
undergoing tubal ligation have varied greatly,
from 0.7 to 43% around a mean of 4%
(Eskenazi and Warner, 1997 ). However, up
to 90% of these women were diagnosed with
minimal or mild endometriosis.
Prevalence and Incidence of
Endometriosis
The National Women’s Health Information
Center, NICH, NIH:
10 to 20 percent of American women of
childbearing age have endometriosis; up to 2
million women in the UK.
The National Women’s Health Information
Center, Bioscience:
approx 1 in 20 or 5.00% or 13.6 million people
in USA ()
PREVALENCE OF PELVIC PAIN
(selected studies)
Authors,
Country
Number of
subjects
Class age
Jamieson
701
18-45
Steege,
1996
Mathias, 5263 (phone
18-50
1996, USA
interview)
Zondervan
Review
Fertile age
1998, UK
Zondervan
2001, UK
3916 (postal
quest)
18-49
Prevalence
39
15
10-50
24
PREVALENZA DI ENDOMETRIOSI
SECONDO INTERVENTO E DIAGNOSI
50
40
30
Prevalenza
endometriosi
20
10
0
LPS
LPT
VAG
TC
STERILI CISTI OV
U.O. Ostetricia Ginecologia 1 – A.O. della Provincia di Lodi, 2005
PREVALENCE OF
ENDOMETRIOSIS
Female population
unknown
In gynecological laparotomies
1-50%
In gynecological laparoscopies
5-53%
In infertile women
15-24%
In unexplained infertility
70-80%
In female population (estimated) 2%
In laparoscopic sterilization
2-4%
K.W. Schweppe, 1988
ENDOMETRIOSI NELLE
ADOLESCENTI
L’incidenza di endometriosi nelle
adolescenti è tuttora sconosciuta.
Vercellini (1989) 38%
Reese (1996)
73%
10% of women in the reproductive age
group have endometriosis
30-50% of infertile women have
endometriosis
Occurs primarily in women in their 20's and
30's
Once thought that middle-class, white
patients who are high achievers and
perfectionists were at higher risk
Int J Gynaecol Obstet. 1997
ESTIMATED PREVALENCE OF ENDOMETRIOSIS:
REVIEW OF THE LITERATURE
Diagnostic procedure
Author and year
%
Sterilization
Strathy (1982)
Kirshon (1989)
Drake (1980)
Kresch (1984)
Liu (1986)
Moen (1991)
Mahmood (1991)
Drake (1980)
Mahmood (1991)
Hasson (1976)
Kresch (1984)
Mahmood (1991)
Hasson (1976)
2
7
5
15
43
19
19
48
21
23
32
15
12
Laparoscopy for infertility
Laparoscopy for pelvic pain
Haleh Sangi-Haghpeykar, Alfred N. Poindexter III
Obstet Gynecol 1995;85:983-92
Eric Daiter, M.D
Endometriosis: incidence
rates
The literature on the prevalence of endometriosis in selected groups of
women suggest a 2% rate for those undergoing elective tubal sterilization, an
8-12% rate for those undergoing hysterectomy, a 30% rate for those
undergoing operative laparoscopy and a 55% rate for teenagers undergoing
diagnostic laparoscopy for pelvic pain.
In 1987, the "National Center for Health Statistics" report on hysterectomies
performed in the USA between 1965 and 1984 described about 2 million US
women with a diagnosis of endometriosis who had a hysterectomy. An
interesting finding from this report was that the number of women with
endometriosis having a hysterectomy increased steadily throughout the target
time period, with less than 150,000 women in 1965-67 and greater than
350,000 women in 1982-84. This increase was not fully accounted for by an
increase in hysterectomies in general and occurred during a time when
increasingly conservative management for endometriosis became popular.
Therefore, the increase may reflect an increase in the incidence or severity of
endometriosis in the USA.
Trattamento chirurgico della sterilità
associata a endometriosi I-II stadio
Trattamento chirurgico della sterilità
associata a endometriosi III-IV stadio
endometriosi
L’incidenza della endometriosi
nella polazione femminile in età
fertile, varia tra il 7 e 10%.
endometriosi infiltrante del culde-sac anteriore
l
l’1% delle donne affette da endometriosi
presentano lesioni del tratto urinario, l’84%
delle quali coinvolgono la vescica
99%
84%
1%
16%
endometriosi infiltrante del culde-sac anteriore
l
due forme distinte di endometriosi del detrusore:
l
spontanea
l
l
l
contemporanea presenza di
patologia più generalizzata
il nodulo ha origine nella cupola
vescicale
iatrogena
l
disseminazione intraoperatoria in
corso di taglio cesareo
endometriosi infiltrante
ureterale
l
l
l
l
l
l
rara (tra 0.01% e 0.6%)
origina dall’estensione di un impianto pelvico
peritoneale lungo la faccia laterale gonadica e la
fossetta ovarica
spesso coesiste una endometriosi ovarica
lesioni ostruttive del terzo distale, pressoché
esclusive sul lato sinistro (50% - fossetta ovarica,
50% legamento utero-sacrale)
intrinseca: tessuto endometriosico nell’ambito di
una muscularis iperplastica e fibrotica
estrinseca: restringimento del lume da
compressione e/o fibrosi
L’ENDOMETRIOSI PROFONDA
Definizione : lesione profonda >= 5 mm.
11-16 % dei casi di endometriosi presenta localizzazioni profonde,
di cui:
55 % Douglas
35 % leg. utero-sacrali
11% setto retto-vaginale
5 % retto-sigma
2-4 % vie urinarie ( 25-30 % rene escluso !)
INCIDENZA ENDOMETRIOSI
MINIMA-LIEVE
7-10%
20-70 %
70-80%
40%
nella popolazione generale
nelle pazienti infertili
nelle pazienti con dolore
pelvico cronico
donne asintomatiche
PREVALENZA DI ENDOMETRIOSI IN DONNE
SOTTOPOSTE AD INTERVENTO (Parazzini,
1994)
DIAGNOSI
Sterilità
Dolore pelvico
Fibromi
Cisti ovarica
95% confidence
30
45
12
35
26-35
39-52
10-14
31-40
L’ ENDOMETRIOSI PROFONDA
Chirurgia del setto retto-vaginale : quando intervenire
- sintomi presenti ( dispareunia, dismenorrea)
- massa pelvica da definire
- infertilità
Indagini diagnostiche : eco transrettale, RMN
Tecnica : isolamento del nodulo a partire dal connettivo lasso
extraperitoneale procedendo in senso centripeto verso la lesione
- se lesione è molto laterale : tecnica di Hudson per il cancro
infiltrante
- eventuale resezione vaginale se coinvolta la mucosa vaginale
L’ ENDOMETRIOSI PROFONDA
Chirurgia del retto-sigma : quando intervenire
- se lesione sintomatica : dischezia, dispareunia, sindrome subocclusiva
( 30 % asintomatica)
- se sintomo algico : escissione di losanga parietale a mucosa integra
- se sintomo meccanico : resezione intestinale con anastomosi T- T
Ausili diagnostici : clisma opaco, rettosigmoidoscopia, RMN
NB: lasciare isolata una piccola area di endometriosi rettale (malattia
residua) non comporta un maggiore rischio di recidiva del sintomo
NB: in caso di soluzione di continuo sutura laparoscopica in duplice
strato
NB: ricordare che è lesione benigna: ampi interventi demolitivi sul
tubo digerente sono giustificati solo su casi molto selezionati
L’ENDOMETRIOSI PROFONDA
Chirurgia delle vie urinarie : quando intervenire
vescica (1%): lesione sintomatica ( dolore, disuria,
stranguria, ematuria)
NB: la lesione coinvolge sempre la tonaca muscolare
tecnica : escissione possibilmente extramucosa con sutura
in unico
o duplice strato (muscolare-mucosa e sierosa)
uretere (1%): coinvolto quasi sempre ab estrinseco
la lesione va sempre trattata ( valutare rene escluso)
tecnica : ureterolisi
ureteroureterostomia
ureteroneocistostomia
Il trattamento dell’endometriosi lieve
Familiarità
Le donne con una parente di I grado
affetta da endometriosi hanno un
rischio aumentato da 6 a 10 volte di
ammalarsi
Animal Studies in Endometriosis: A Review
Lisa Story and Stephen Kennedy
ILAR Journal, Volume 45, Number 2 2004
Risk factors associated with endometriosis include the
following: increasing age within the reproductive years,
greater exposure to menstruation because of short
cycle
length, long duration of flow and reduced parity, and
increased peripheral body fat associated with
increased serum estrogen levels. Factors thought to
decrease estrogen levels (e.g., exercise and smoking)
show an inverse relation with the disease (Eskenazi
and Warner 1997).
Apart from generally consistent
associations with increasing age and
prolonged menstruation, other findings
such as for smoking, exercise, body
mass index, parity and tampon use
were either inconsistent or simply not
tested in more than one study (Eskenazi
and Warner, 1997
L’ENDOMETRIOSI DELL’ OVAIO
Patogenesi : invaginazione della corticale adesa all’endometriosi
peritoneale
Sintomatologia :
- per coinvolgimento peritoneale
- per rapida crescita della cisti
Tecnica : stripping della capsula dopo completa mobilizzazione
dell’annesso
Vantaggi della enucleazione :
-minore rischio di recidiva ( circa 6-8 %)
-comparsa di recidiva dopo intervallo più lungo
-pregnancy rate significativamente più elevata ( 67 vs 23 %)
( Busacca : studio randomizzato stripping vs diatermocoagulazione)
Fert-Steril 1998; 70 , 6
Escludere sempre localizzazioni profonde ed extraperitoneali
ENDOMETRIOSIS AND
INFERTILITY
• There are two published RCTs comparing diagnostic
laparoscopy alone to surgical ablation of minimal-mild
endometriosis.
• In the study by Marcoux et al 50/172 women in the
treatment group became pregnant and had pregnancies
that continued beyond 20 weeks compared to 29/169 in
the non-treatment group (cumulative probabilities 30.7%
and 17.7% respectively).
• However, in a smaller study by Parazzini 10/51 women
(19.6%) in the treatment group as opposed to 10/45
women (22.2%) in the control group became pregnant
within one year following laparoscopy suggesting no
difference. Thus the two studies disagree. Although the
study by Marcoux et al was larger, neither study was
Laparoscopia nelle donne infertili
con endometriosi minima o lieve
Laparoscopia
Operativa
Laparoscopia
Diagnostica
N°Pazienti
54
47
N°Pazienti che
hanno cercato
gravidanza
51
45
N°gravidanze
12 (24%)
13 (29%)
n.s.
N°aborti spontanei
2 (3,9%)
3 (6,6%)
n.s.
10 (19.6%)
10 (22.2%)
n.s.
Birth Rate
P
F. Parazzini Hum Repr 1999 May; 14(5):1332-4
% 60
LAPAROSCOPIA
DIAGNOSTICA ed
INFERTILITA’
54,7
50
40
età 32,7 +/- 3,6
(range 24-41)
30
20
15,6
11
10
9,3
4,6
4,6
0
S. Insp.
Ster. II
Endom.
F. tub.
indicazioni
Ader.
F. Masch.