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  1. 1. DR. SHASHWAT JANI M.S. ( GYNEC ) DIPLOMA IN ENDOSCOPY. Assistant Professor, dept. of obs – gyn, Smt. N.h.l. municipal medical college , Sheth v.s. general hospital Ahmedabad, gujarat , india.. MOB : +91 99099 44160. E-mail : drshashwatjani@gmail.com drshashwatjani@gmail.com 1
  3. 3. drshashwatjani@gmail.com 3
  4. 4.  Endometriosis initially described by Von Rokitansky in 1860  Endometriosis is a clinical and pathological entity.  It is characterized by the presence of tissue resembling functional endometrial glands and stroma outside the uterine cavity.  It is not a neoplastic condition, but malignant transformation is possible. drshashwatjani@gmail.com 4
  5. 5. ABDOMINAL Most common site - OVARY (44% involved) Pouch of Douglas Uterosacral ligament Broad ligament Rectovaginal septum Pelvic lymph node Rare sites - Gut, Appendix, Ureter, Urinary Bladder drshashwatjani@gmail.com 5
  6. 6. drshashwatjani@gmail.com 6
  7. 7. EXTRA-ABDOMINAL Common sites - Abdominal scar of Hysterotomy, Caesarean Section, Tubectomy, Myomectomy Umbilicus Episiotomy Scar Vagina Cervix Remote sites - Pleura, Lungs, deep tissues of arms, thighs drshashwatjani@gmail.com 7
  8. 8. drshashwatjani@gmail.com 8
  9. 9.  AGE - 30-40 years(most common) - between the menarche and menopause.  FAMILY HISTORY -7 times greater if a 1st degree relative affected by endometriosis.  New study- Early menarche  Late marriage  SOCIAL AND ECONOMIC FACTORS- more common in highly civilized communities.  PARITY- 50-70 % affected women are childless. drshashwatjani@gmail.com 9
  10. 10.  Retrograde menstruation (Sampson’s theory)  Metaplasia of coelomic epithelium (Meyer and Ivanoff)  Lymphatic dissemination  Haematogenous Spread  Hereditary factor  Immunologic factor drshashwatjani@gmail.com 10
  11. 11.  John Sampson first postulated that endometriosis arose from retrograde flow of fragments of endometrial tissue through the oviducts and into the peritoneal cavity.  Epidemiologic data suggests that women who menstruate more frequently, more heavily, or for a longer duration have increased chance of disease development.  There is retrograde flow of menstrual blood through the uterine tube during menstruation. The endometrial fragments get implanted in the peritoneal surface of pelvic organs( Sites– ovaries, uterosacral ligament)  Anomalies of the Mullerian tract, increased occurrence of endometriosis and stenosis of external cervical os. drshashwatjani@gmail.com 11
  12. 12. drshashwatjani@gmail.com 12
  13. 13.  In this theory, the germinal epithelia of the ovary, endometrium and peritoneum all originate from the same totipotential coelomic epithelium.  In coelomic Metaplasia, these totipotential coelomic cell are transformed by repeated exposure to hormonal or infection stimuli.  Development of endometriotic lesions in unusual locations.  Prolonged treatment with estrogen. drshashwatjani@gmail.com 13
  14. 14. Endometrial cell can be transported to extrauterine sites by blood vessels or the lymphatic system or by contamination of the pelvis or abdominal wall incision, if the uterine cavity is surgically entered. drshashwatjani@gmail.com 14
  15. 15.  In cellular immunity, can facilitate the successful implantation of translocated endometrial cells.  In endometriosis lymphocytes decreased cytotoxic response to endometrial cell may be due to defect in natural killer cell activity, such as a decreased lytic effect toward stroma that allow ectopic development of endometrial fragments. There may be increased resistance of endometrium in women with endometriosis to natural killer cytotoxicity. drshashwatjani@gmail.com 15
  16. 16.  Endometriosis is an estrogen-dependent condition.  Estradiol concentration greater than 60pg/ml is necessary for proliferation of endometrial lesions.  Estrogen & Progesterone receptors are found in much lower concentrations in endometriotic tissue than in normal endometrial tissue,  Growth factors can originate from the peritoneal environment to stimulate endometrial development.  Platelet derived growth factor, macrophage secretory products enhance endometrial stromal cell proliferation. drshashwatjani@gmail.com 16
  17. 17.  Increased concentration of macrophages derived growth factors including vascular endothelial growth factor.  Molecular alterations in steroidogenic enzyme function have been implicated in the pathogenesis of endometriosis.  Menstrual effluent contains factors that induce alterations in the peritoneal mesothelium, facilitating adhesions of endometrial cells. drshashwatjani@gmail.com 17
  18. 18. Symptoms:-  PELVIC- Dymenorrhoea(50%), Abnormal menstruation(60%) Dyspareunia, Chronic Pelvic Pain, Premenstrual spotting  GASTROINTESTINAL- Constipation, Diarrhea, Hematochezia, Tenesmus  URINARY COMPLAINTS- Flank pain, Back pain, Abdominal pain, Urgency, Frequency,Hematuria  PULMONARY- Haemoptysis , Pneumothorax  INFERTILTY drshashwatjani@gmail.com 18
  19. 19.  Most common symptom  Pain starts a few days prior to menstruation, gets worse during menstruation( secondary dysmenorrhoea)  Pain due to Increased secretion of PGF2α, Thromboxane β2 from endometriotic tissue. Abnormal Menstruation  Menorrhagia is a predominant abnormality. Polymennorhoea, premenstrual spotting also occur. drshashwatjani@gmail.com 19
  20. 20.  It is usually deep, due to stretching of the structures of the Pouch of Douglas or direct contact tenderness found in endometriosis of rectovaginal septum or Pouch of Douglas and with fixed retroverted uterus. Abdominal pain  lower abdominal pain or backache  May be due to inflammation in peritoneal implants due to cystic bleeding  Irritation or invasion of nerve  Action of inflammatory cytokines released by the macrophages. drshashwatjani@gmail.com 20
  21. 21. Infertility Mechanical interference--- 1. Pelvic adhesions 2. Chronic salpingitis 3. Impaired oocyte pickup 4. Altered tubal motility 5. Distortion of tubo-ovarian relations Alteration in peritoneal fluid 1. Increased concentration of prostaglandins 2. Increased number of macrophages 3. Increased production of cytokines 4. Phagocytosis of sperms Abnormal Systemic Immune system 1. Increased cell-mediated gametes injury 2. Increased prevalence of autoantibodies Hormonal or ovulatory dysfuntion 1. Defective folliculogenesis 2. Luteinized unruptured follicle syndrome 3. Hyperprolactinemia 4. Luteal phase deficiency 5. Implantation failure drshashwatjani@gmail.com 21
  22. 22. General conditions- Fair Pallor + due to Menorrhagia Pulse, B. P. –Normal CVS/ RS – Normal P/A- Mass felt in lower abdomen arising from the pelvis Enlarged chocolate cyst or tuboovarian mass, due to endometriotic adhesions. The mass is tender with restricted mobility. L/E-See Vulva and other structures P/S- See cervix, vagina for any deposits, discharge or growth. drshashwatjani@gmail.com 22
  23. 23. o Tender uterosacral ligament o Cul-de-sac nodularity found o Induration of the rectovaginal septum o Fixed retroversion of the uterus o Adnexal masses and generalized or localized pelvic tenderness present o Uterosacral nodules may be found drshashwatjani@gmail.com 23
  24. 24. drshashwatjani@gmail.com 24
  25. 25. drshashwatjani@gmail.com 25
  26. 26.  ASRM staging has poor correlation with pregnancy rate.  In 2009 new staging system was proposed called Endometriosis Fertility Index.  EFI is numerical measure of functional anatomy based on assessment of tubes, fimbriae and ovaries.  EFI score 0 to 10 (0 – poorest and 10 – the best prognosis). drshashwatjani@gmail.com 26
  27. 27. Diagnosis made by Clinical Presentation Clinical Examination  Clinical examination- In many women with endometriosis no abnormality is detected during the clinical examination.  The clinical examination may have false-negative results. So, the diagnosis of endometriosis should be confirmed by biopsy of suspicious lesions or by laparoscopy. drshashwatjani@gmail.com 27
  28. 28.  Transvaginal or Transrectal ultrasonography is an important diagnostic tool in the assessment of ovarian endometriotic cysts, adnexal masses. ( Sensitivity-97% and Specificity-96% )  Other imaging techniques are- CT/ MRI Can be used to provide additional and confirmatory information but they cannot be used for primary diagnosis. drshashwatjani@gmail.com 28
  29. 29.  Cancer Antigen-125, a high molecular weight glycoprotein expressed on the cell surface of some derivatives of embryonic coelomic epithelium.  It is elevated towards the end of the luteal phase and during menstruation.  In many other conditions elevated CA-125 concentration like PID, adenomyosis, uterine leiomyoma, menstruation, pregnancy, epithelial ovarian cancer, pancreatitis, chronic liver disease. drshashwatjani@gmail.com 29
  30. 30.  80% of women with pelvic pain and endometriois had a CA- 125 titre greater than 16 U/ml  6% of patients with pelvic pain and without endometriosis had an increased CA-125.  The result of most studies suggest that CA-125 is not sufficiently sensitive to identify lesser stages of endometriosis.  CA-125 is not reliable as a screening test. drshashwatjani@gmail.com 30
  31. 31. drshashwatjani@gmail.com 31 Diagnostic Laparoscopy is the gold standard investigation for Endometriosis.  In laparoscopy examination, we classify the extent and severity of disease.  In laparoscopy evaluation, a double puncture technique is essential.  The forceps placed through the lower abdomen sheath permits mobilization of the tube and ovaries.  Inspect the lateral side wall, all ovarian surface, both sides of the broad ligament, the bladder, bowel serosa, inferior aspect of cul-de-sac, evaluation of the uterosacral ligaments and rectal serosa.  To avoid under diagnosis it should not be performed during or within 3 months of hormonal therapy.
  32. 32. drshashwatjani@gmail.com 32
  33. 33.  Typical “powder-burn or “gunshot” lesions on the serosal surface of the peritoneum. These lesions are black, blue or dark brown, nodules or small cysts containing old hemorrhage surrounded by variable degree of fibrosis.  White lesions are predominantly fibromuscular. Scarring with scattered glandular and stromal elements.  Brown lesions are mainly haemosiderin deposits. Peritoneal defect and subovarian adhesions contain endometriosis in 40% -70%. drshashwatjani@gmail.com 33
  34. 34. drshashwatjani@gmail.com 34
  35. 35.  For ovarian endometriosis- Large ovarian endometriotic cysts are usually located on the anterior surface of the ovary and associated with retraction, pigmentation and adhesions to the posterior peritoneum. Size smaller than 12 cm in diameter for diagnosis.  Ovarian endometriotic cyst contain a thick, viscous dark brown fluid.(Chocolate fluid) Chocolate cysts– sometimes it is confused with hemorrhagic corpus luteum cysts and neoplastic cysts. Biopsy must be done. drshashwatjani@gmail.com 35
  36. 36. drshashwatjani@gmail.com 36
  37. 37. Pelvic pain & suspected endometriosis NSAID or OCP Success Continue drug therapy Failure Empirical GnRH agonist therapy + estrogen success progestin add back therapy failure continue drug therapy operative laparoscopy GnRH agonist therapy + estrogen progestin add back therapy drshashwatjani@gmail.com 37
  38. 38. Progestogens : Route Dose Frequency Medroxy progesterone acetate oral 30mg Daily Megestrol acetate oral 40 mg Daily Lynoestrenol oral 10mg Daily Dydrogesterone oral 20-30mg Daily Antiprogestins : Gestrinone oral 1.25/2.5mg Twice weekly Danazol oral 400mg Daily Gonadotropin-releasing Hormone Leuprolide s.c. 500mg Daily I.M. 3.75mg Monthly Goserelin S.C. 3.6 mg Monthly Buserelin Intranasal 300ug Daily Nafarelin Intranasal 200ug Daily Triptorelin I.M. 3.75mg Monthly drshashwatjani@gmail.com 38
  39. 39.  Progestogens suppress ovarian steroidogenesis and promote endometrial glandular atrophy, apoptosis and extensive decidual transformation to the stroma.  Progestogens oppose the growth-promoting effect of estrogens on the endometrial tissue by altering the clearance of the nuclear estrogen, receptor and inducing 17 β hydroxysteroid dehydrogenase which convert estradiol to the weaker estrone.  They- prevent reflux menstruation - prevent implantation and growth of regurgitated endometrium. - Progestogens have anti-inflammatory effect. Side effects weight gain, edema, irritability. drshashwatjani@gmail.com 39
  40. 40.  Danazol is a synthetic derivative of 17α-ethinyl testosterone that was introduced into clinical practice by Greenblatt in 1971.  The pharmacologic action of Danazol is complex, directly inhibiting GnRH secretion. Midcycle LH surge is ablated although basal gonadotropin concentrations are maintained.  Direct inhibitions of steroidogenesis, increased metabolic clearance of estradiol and progesterone. Side effects- Weight gain, muscle cramps, increase breast size, vasomotor symptoms. drshashwatjani@gmail.com 40
  41. 41.  GnRH agonists bind to pituitary GnRH receptors and stimulate LH and FSH synthesis and release.  Agonists have much longer biologic half-life(3-8 hours) and GnRH have(3-5 mint) continuous exposure of GnRH receptors to GnRH agonist activity.  Ovarian steroid production is suppressed. Side effects- Hypoestrogenism, hot flushes, vaginal dryness, osteoporosis drshashwatjani@gmail.com 41
  42. 42.  This drug act by interrupting local estrogen formation  With in the endometriosis implant themselves they also inhibit estrogen production in the ovary,brain and other source. Side effect : Bone loss,development of multiple follicles cyst at ovulation. drshashwatjani@gmail.com 42
  43. 43.  When medical measures fail surgical intervention is needed.  In most women with endometriosis, preservation of reproductive function is most important.  The goal of surgery is to excise all visible endometriotic lesions and associated adhesions like peritoneal lesions, ovarian cysts, deep rectovaginal endometriosis and restore normal anatomy.  Laparotomy should be reserved for patients with advanced stage disease, who cannot undergo a laparoscopic procedure and for those in whom fertility conservation is not necessary. drshashwatjani@gmail.com 43
  44. 44. drshashwatjani@gmail.com 44
  45. 45.  Conservative resection of disease by Laparotomy is most valuable in case of extensive dense pelvic adhesions or endometriomas greater than 5 cm in diameter.  Deep involvement of the rectovaginal septum with fibrotic extension into perirectal fossa. Invasion of the bowel muscular and endometriotic infiltration in the region of uterine vessels and ureter. Are generally best approched through the open abdomen.  Peritoneum – Small lesions of superficial peritoneal endometriosis less than 5 mm in diameter are easily treated with laser or bipolar coagulation or constant stream of irrigation. drshashwatjani@gmail.com 45
  46. 46. DIE CLASSIFICATION OPERATIVE PROCEDURE (A) Anterior DIE A1 : Bladder Laparoscopy partial cystectomy (P) Posterior DIE P1 : Uterosacral Laparoscopic resection of ligament uterosacral ligament P2 : Vagina Laparoscopic assisted vaginal resection of DIE infiltrating the posterior fornix. P3 : Intestine w/o vaginal infiltration ---- Intestinal resection by laparoscopy or by Laparotomy with vaginal infiltration ---- Laparoscopically assisted vaginal intestinal resection or by Laparotomy Multiple intestinal location ---- Intestinal resection by Laparotomydrshashwatjani@gmail.com 46
  47. 47.  Surgical treatment of endometriosis less than 4-5 cm in diameter.  Technique is initiated by longitudinally incising the cortex overlying the cyst after achieving full mobilization of the ovary.  Incision is made along the inferior pole on the opposite side to the hilus to preserve the opposite side of ovarian tissue to the fimbria.  The cyst contents are immediately drained with suction cannula and cavity is irrigated and inspected for papillary structure.  Very small endometriosis less than 1-2 cm in size may be effectively treated by electro coagulation of the mucosal lining. drshashwatjani@gmail.com 47
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  49. 49.  Also called uterine endometriosis, in which islands of endometrium are found in the wall of the uterus.  Observed commonly in elderly women.  Often coexists with uterine fibromyomas, pelvic endometriosis, endometrial carcinoma.  Gross- Uterus appears symmetrically enlarged.  Histology- Islands of endometrial glands surrounded by stroma.  C/F- Menorrhagia, progressively increasing dysmenorrhoea, pelvic discomfort, backache, dyspareunia. drshashwatjani@gmail.com 49
  50. 50.  C/E- Symmetrical enlargement of uterus, tender uterus.  Treatment- Diagnostic Hysteroscopy combined with curettage.  Elderly- Total hysterectomy -NSAID’s -Hormonal therapy. Drugs- Danazol, GnRH. drshashwatjani@gmail.com 50
  51. 51. THANK YOU drshashwatjani@gmail.com 51