2. Introduction
one of the most common diseases but it is also one of the least understood
endo=within, metri= uterus (womb), osis=condition
The presence of functioning endometrium(glands and stroma) in sites other
than uterine mucosa is called endometriosis.
These ectopic endometrial tissues may be found in the myometrium then it is
called endometriosis interna or adenomyosis.
More commonly these tissues are found at sites other than uterus then it is
called as endometriosis externa or generally referred to as endometriosis.
endometriosis is not cancer and there is no cure for it
3. PREVALANCE
found in 12-15 % of women (5 million women in the US).
21-47% of infertility cases
primarily found in women during their child-bearing years
common among adolescents
Severe disease may occur in families
More in women whose first degree relative have the disease
Exposure to ovarian hormones appears to be essential
No known racial or socioeconomic predilection
Often diagnosed incidentally
5. PATHOGENESIS
Sampson's theory:
Retrograde menses and peritoneal implantation
Most women retrograde menstruate
Meyer's theory:
Coelomic metaplasia
Low incidence of pleural disease
Halban's theory:
Hematogenous or lymphatic spread to distant tissues
Does not explain gravity dependent disease sites
Immunogenic defect
6. PATHOLOGY
These ectopic foci respond to cyclic hormonal fluctuations in
much the same way as intrauterine endometrium, with
proliferation, secretory activity, and cyclic sloughing of
menstrual material.
The products of this metabolic activity, including the
concentrated and cyclic release of cytokines and
prostaglandins, lead to an altered inflammatory response
characterized by neovascularization and fibrosis formation.
Some investigators have been able to demonstrate abnormal T-
and B-cell function, abnormal complement deposition, and
altered interleukin (IL)-6 production in women with this
disease.
7. PATHOLOGY
If it happens to occur on the pelvic peritoneum, it provides adhesions and
puckering of the peritoneum
Endometrioma
o If encysted the cyst enlarges with cyclic bleeding and the content inside
becomes chocolate colored
o Contains blood, fluid & menstrual debris
o Hence the cyst is called chocolate cyst which is commonly located in
the ovary.
o Brown to black color due to Hemosiderin
o Chocolate cyst may also be due to hemorrhagic follicular or corpus
luteum cyst or bleeding in to a cyst adenoma. for this reason, the term
endometrial cyst or endometrioma is preferred to chocolate cyst
8. PELVIC ENDOMETRIOSIS
Typically there are small black dots, the so called ‘power burns’ seen
on the uterosacral ligaments and pouch of douglas.
Fibrosis and scarring in the peritoneum surrounding the implants is
also a typical finding
Other subtle apperances:
Red flame shaped areas
Red polypoid areas
Yellow brown patches
White peritoneal areas
Circular peritoneal defects.
9. Symptoms
According to site
No relation between extent of the
disease and severity of the symptoms
Female reproductive tract:
o Dysmenorrhea
o Lower abdominal and pelvic pain
o Dyspareunia
o Accident to endometriotic cyst
o Low back pain
o Infertility
o Menstrual irregularity .
Urinary tract:
o Cyclical haematuria / dysuria
o Ureteric obstruction
Gastrointestinal tract:
o Dyschezia
o Cyclical rectal bleeding
o Intestinal obstruction
Lungs
o Cyclical hemoptysis
o Blood stained Pleural effusions
o Catamenial Pneumothorax
10. Diagonosis
Serum CA 125
Sensitivity 28% & specificity 90%
Not useful for screening, because of poor sensitivity
Can be used to identify a sub-group of women who are likely to benefit
from early laparoscopy & to follow the progress of disease after
establishing the diagnosis
Ultrasound:
Sensitivity for focal endometrial implants is poor
CT scan
Endometriomas may appear solid, cystic or mixed
Because of poor specificity & high radiation, CT has been replaced by MRI
MRI
Role is limited in visualizing small endometriotic implants and adhesions
More useful for lesions in extraperitoneal locations & the contents of pelvic
mass
More frequently used in staging & treatment response monitoring
Direct visualization of the lesion
Laparascopy
Laparatomy
Histopathology to confirm the diagnosis
11. Staging
– American society of Reproductive Medicine, 1996
Stage I – Minimal
Isolated superficial implants,
No adhesions
Stage II – Mild
More superficial implants (<5cm),
No significant adhesions
12. Stage III – Moderate
Multiple superficial & invasive
implants,
Peritubal & Periovarian adhesions may
be present
Stage IV – Severe
Multiple implants,
Ovarian endometriomas,
Many dense adhesions
14. Expectant management
Young , asymptomatic infertile patient with mild endometriosis.
If pregnancy does not achieved within 12 - 18 months of observation,
hormonal or surgical treatment is indicated .
Medical Treatment
Symptomatic patients with minimal or mild lesions
NSAIDs
Opioids.
Hormonal Treatment
Ovary Estrogen
Endometriosis
Tissue
Progestin
Oral contraceptives
Danazol
GnRH agonists
15. Surgical management
Conservative – Excision, Cauterization & Evaporation
Surgeries for pain - Uterosacral Nerve Ablation (LUNA), Presacral
Neurectomy
Radical surgeries - Hysterectomy
Surgeries for Endometrioma – Cystectomy, Drainage & coagulation,
Fenestration
Laparoscopy
removes adhesions, implants, or endometiromas
exam with a hollow, lighted tube that slips into the abdomen through a small
incision near the navel, done under general anesthesia
only sure way to diagnosis endometriosis
fluid drained and small patches of endometriosis destroyed using a laser or
electrical current
possibility of shoulder pain after operation, caused by absorption of carbon
dioxide gas (instilled in abdominal cavity during surgery to help assist in
visualization for the surgeon)
Laparotomy
more extensive procedure, full abdominal incision, longer recovery period
(4-6 weeks)purpose: perform delicate microscopic surgery
16. This March marks the 15th annual health awareness month recognition of Endometriosis
Awareness Month.
17. Conclusion
• Endometriosis is a mystery tour as it requires decision
making at every stage by the physician and the
patient.
• Endometriosis still stand as one of the most-
investigated disorders in gynecology. So is one of the
highest priorities for research.
