3. History
• In 1981 , Chatman observed that unsuspected
Endometriosis could be found in peritoneal
pockets.
• In 1986 , Jansen & Russel published their
observations on non-pigmented Endometriosis.
• They concluded that:
Visualization of pigment is not necessary to
diagnose E.
Endometriosis in earlier stages of histogenesis
may display only non-pigmented lesions.
9. SUBTLE LESIONS
I- RED lesions:
• Red flame-like lesions: more commonly affecting
the broad ligament & uterosacral ligaments.
Histologically: active E surrounded by stroma
• Glandular excrescences: resemble the
mucosal surface of the endometrium.
Histologically: numerous endometrial glands.
• Areas with hypervascularization: resemble the
peticheal lesions due to manipulation of the
peritoneum or to hypervascularization of the
peritoneum.
10.
11.
12.
13.
14. II- White lesions:
• White opacification: appears as peritoneal
scaring or as circumscribed patches often
thickened & sometimes raised.
Histologically: an occasional retroperitoneal
glandular structure&scanty stroma surrounded
by fibrotic tissue or connective tissue.
• Subovarian adhesions:
Histologically: connective tissue with sparse
endometrial glands
15. • Yellow-brown peritoneal patches: resembling
café au lait patches.
Histologically: similar to those observed in white
opacification, but haemosiderin among the
stroma cells produces the café au lait colour.
• Circular peritoneal defects: frequently occur in
areas of the pelvis which overlie loose
connective tissue.
80% of peritoneal defects are associated with E,
either on the border of the defect or in the
defect itself (Donnez et al,1992)
16.
17.
18.
19. Non-visible endometriosis
• Biopsies were taken from visually normal
peritoneum of the uterosacral ligaments.
• Histological study revealed the presence of
endometriotic tissue in about 6% of infertile
women without endometriosis.
Nezhat F et al, 1991, Walter AJ et al, 2001.
20. Prevalence
• Diagnosis of SE increased from 15% in 1986
to 65% in 1988 (Nisole et al,1993).
• SE are more common than the classic lesions
in the adolescents with pelvic pain (Davis et
al,1993).
• The incidence decreases with age (Konincks et
al,1991).
• The most common is white opacification of
the peritoneum
• The least common, but nevertheless
characteristic, is the red flame like (Jansen &
Russel,1986).
21.
22. Biological activity
• Subtle endometriosis are thought to be
more biologically active than typical forms.
• The red petechial implants produce twice
the amount of PGF than brown lesions,
which in turn produce more PGF than typical
powder-burn implants.
24. •Infertility:
SE is the most common single cause of
unexplained infertility.
(Propst & Laufer,1999).
25. •Pain:
Endometriosis occurs in approximately 70%
of adolescent girls with chronic pelvic pain not
responding to conventional medical therapy
and the majority of patients have stage I
disease.
(Ivo Brosens et al, 2013)
26. Acquired deep dysparunia was found in 18% of
SE (Jansen & Russel,1986).
• On other hand, Vercellini et al(1996) observed that
deep dysparunia was associated only with typical E &
not with SE
Increasing dysmenorrhea suggestive of active E
is present in 64% of SE (Tansen & Russel,1986).
• The number of typical or S implants did not correlate
with the severity of dysmenorrhea (Muzii et al,1997).
28. Diagnosis
•Standard laparoscopy:
Negative laparoscopy results do not mean
that the patient has no E (Martin,1999)
•Laparoscopy under hydroflotation:
Using lactated Ringer or normal saline
introduced into the pelvis (Laufer,1997).
•Near-contact laparoscopy
Visualization at magnifications of 1- to 7-
power (Redwin,1987)
29. •Peritoneal blood painting :
SE can be seen more easily by painting the peritoneal
surface with bloody peritoneal fluid.
The physical- chemical properties of blood cause it to
interact with S. physical deformities of the peritoneal
surface in such a way as to cause flowing erythrocytes
to outline surface irregularities. (Redwin,1989)
•E. Bubble test :
During laparoscopy, the cul de sac is irrigated with
short bursts of saline under controlled pressure.
Development of dense soap like bubbles staying for at
least 5 seconds indicates a positive test.
The positivity of the test is apparently related to
increased level of triglycerides in peritoneal fluid in
cases of E. (Amer A & Omar M., 2002)
30. •Transvaginal hydrolaparoscopy:
Superior to standard laparoscopy for detection
of Subtle endometriotic adhesions of the
ovary(Brosen et al,2001)
•Elevated serum levels of endometrial
secretory protein (placenta protein 14)
The highest levels in patients with E are found
on days 1 to 4 of the cycle (Seppala et al,1989)
•Histopathologic examination:
Biopsy taken from suspected lesions.
31. Differential diagnosis
• Hemangiomas.
• Old suture.
• Reaction to oil-contrast medium.
• Epithelial inclusions.
• Secondary breast & ovarian cancer.
• inflammatory cystic inclusions.
• Walthard rests, adrenal rests
Differentiation between SE & above lesions may be
impossible visually but may be achieved histologically
32. TREATMENT
• Aim of treatment:
Reduce pain.
Increase the possibility of pregnancy.
Delay recurrence for as long as possible.
33. • Ideal Goal (ASRM recommendation):
Endometriosis should be viewed as a
chronic disease that requires a life-long
management plan
with the goal of maximizing the use of
medical treatment and avoiding repeated
surgical procedures. Fertil & Steril, 2008
35. Dienogest (Visanne)
• Synthetic oral progestogen with unique
pharmacological properties.
• highly selective for the progesterone
receptor .
36. Dienogest
• 2mg once-daily.
• Can start at any day of menstrual
cycle.
• Must be continued regardless of vag.
Bleeding.
37. • Advantages:
Dienogest appears to be safe and effective
when taken for up to 2 years.
Dienogest is an oral therapy.
Treatment of endometriosis with dienogest
is not inferior to that with GnRH agonists.
38. Meirina ( LNG-IUD)
• Treatment of choice for endometriosis
associated pain in women who do not
wish to conceive:
Effective for at least 5 ys.
Can be reapplied every 5 ys.
No modifications in estrogen levels.
Low-cost therapy.
Fewer side effects than other
progestogenic agents.
39. Aromatase inhibitors
• Idea of use:
In Normal endometrium: No detectable
levels of aromatase activity
In endometriosis: An increased expression
of cytochrome P450 aromatase in
endometrial tissue.
41. Selective Progesterone
receptor modulators
(SPRM)
• Asoprisnil:
It reduce pelvic pain as well as
dysmenorrhea.
Its effect on bleeding pattern is dose-
dependent. (Chwalisz et al, 2004).
• Advantage: No estrogen deprivation.
42. Angiogenesis inhibitors
• Statins:
Inhibit the growth of human endometrial
stromal cells in vitro (Piotrowski et al, 2006).
• Thalidomide:
Angiostatic & Immunomodulatory
Effective in women with relapsing
endometriosis (Scarpellini et al, 2002).
