endometriosis is a common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue ourside the uterus. for more informations you can read this file.

1. Endometriosis
Ghadeer Ismail Eideh
Supervised by Dr. Hilda Slaebi & Dr. Anan Amor

2. Definition
01.
Pathophysiology
02.
Risk factor
03.
Clinical features
04.
Diagnosis
05.
Treatment
06.
Outlines

3. Definition
01.

4. Endometriosis
• Endometriosis is a benign condition in which endometrial
glands and stroma are seen outside the endometrial cavity.

5. Pathophysiology
02.

6. Sampson theory
● Sampson’s implantation theory postulates that it is
this retrograde menstrual regurgitation of viable
endometrial glands and tissue along patent Fallopian
tubes, and that subsequent implantation on the
pelvic peritoneal surface causes endometriosis.

7. Coelomic metaplasia theory
● coelomic epithelium transformation describes the
dedifferentiation of peritoneal cells lining the
Müllerian duct back to their primitive origin, which
then transform into endometrial cells. This
transformation into endometrial cells may be due to
hormonal stimuli or inflammatory irritation.

8. Other theories
● Immune system dysfunction.
● Hematologic dissemination, lymphogenic spread of
endometrial cells.
● Iatrogenic.

9. Pathophysiology
● Most importantly, these endometrial cells are functional,
with estrogen receptors, and are responsive to hormones
in the same way endometrium does under influence of
estrogen (cause of cyclical pain).
• However these cells are slightly different in that they have
high levels of
aromatase enzyme and thus produce their own estrogen,
and secrete pro-inflammatory factors that lead to scarring
and inflammation which leads to adhesions (the cause of

10. Site of endometriosis

11. Site of endometriosis
Ovary
The most common site of endometriosis
is the ovary; because this is functioning
endometrium, it bleeds on a monthly
basis and can create adnexal
enlargements known as endometriomas,
also known as a chocolate cyst.

12. Chocolate cyst

13. Site of endometriosis
Cul-de-sac
The second most common site of endometriosis
is the cul-de-sac, and in this area the
endometriotic nodules grow on the uterosacral
ligaments, giving the characteristic uterosacral
ligament nodularity and tenderness appreciated by
rectovaginal examination. Menstruation into the
cul-de-sac creates fibrosis and adhesions of
bowel to the pelvic organs and a rigid cul-de-
sac, which accounts for dyspareunia.

14. Uterosacral ligament

15. Uterosacral ligament

16. Site of endometriosis
Other rarely sites.
Less commonly, endometriotic deposits can be
found in other sites such as umbilicus, abdominal
scars and the pleural cavity

17. Peritoneal endometriosis

18. Pleural endometriosis

19. Risk factors
03.

20. Late menopause
Family history of
endometriosis
Obesity Genetics factor Infertility
Risk factors
01 02 03
04 05 06
Early menarche

21. Incidence
Years
old
Years
old
5-10%
• Endometriosis occurs in approximately 5–10%
of women of reproductive age.
• Found in approximately 20% of women with
chronic pelvic pain.
• Found in approximately 30% of women with
infertility

22. Epidemiology
• More common in
white and Asian
women than black
and African women.

23. Clinical features
04.

24. Symptoms and signs
● Severe cyclical non-colicky pelvic pain restricted to
around the time of menstruation. Symptoms may begin
a few days before menses starts until the end of
menses.
● Deep pain with intercourse (deep dyspareunia) and on
defecation (dyschezia) are key indicators of the
presence of endometriosis deep within the pouch of
Douglas. Endometriosis in distant sites can cause local
symptoms, for example cyclical epistaxis with nasal
passage deposits and cyclical rectal bleeding with

25. Symptoms and signs
● On examination, pelvic tenderness is common.
● A fixed, retroverted uterus is often caused by cul-
de-sac adhesions.
● Uterosacral ligament nodularity is characteristic.

26. Site Symptoms
Female reproductive
tract
• Dysmenorrhea.
• Lower abdominal pain
• Dyspareunia
• Rupture/ torsion endometrioma
• Low back pain
• Infertility
Urinary tract
• Cyclic haematuria/ dysuria
• Loin/ flank pain
GI
• Dyschezia.
• Cyclic rectal bleeding
• Obstruction
Surgical scar/ umbilicus • Cyclic pain, swelling and bleeding
Lung
• Cyclic hemoptysis.
• hemopneumothorax

27. Diagnosis
05.

28. Diagnosis
01
Ultrasound TVUS can detect endometriosis involving the ovaries (endometriomas
or chocolate cysts)
02
MRI
MRI can detect lesions >5 mm in size, particularly in deep tissues, for example
the rectovaginal septum. This can allow careful presurgical planning in difficult
cases.
03 CA-125
May be elevated
04
laparoscopic
laparoscopic identification of endometriotic nodules or endometriomas is
definitive.

29. Treatment
06.

30. Treatment
● Treatment should therefore be tailored for the
individual according to her age, symptoms, extent of
the disease and her desire to have children.
● Analgesics :
Non-steroidal anti-inflammatory drugs (NSAIDs) are
potent analgesics and are helpful in reducing the severity
of dysmenorrhea and pelvic pain. However, they have
no specific impact on the disease and hence their use is for
symptom control only. The additional use of
codeine/opiates should be avoided as the coexisting
irritable bowel symptoms can be worsened, exacerbating

31. Treatment
Pregnancy:
can be helpful to endometriosis because during this time
there is no menstruation; also, the dominant hormone
throughout pregnancy is progesterone, which causes
atrophic changes in the endometrium. However, infertility
may make this impossible.

32. Treatment
Pseudopregnancy:
achieves this goal through preventing progesterone
withdrawal bleeding. Continuous oral
medroxyprogesterone acetate (MPA [Provera]),
subcutaneous medroxyprogesterone acetate (SQ-DMPA
[Depo-Provera]), or combination oral contraceptive pills
(OCPs) can mimic the atrophic changes of pregnancy.

33. Treatment
Pseudomenopause:
achieves this goal by making the ectopic endometrium
atrophic.
The treatment is based on inhibition of the hypothalamic–
pituitary–ovarian axis to
decrease the estrogen stimulation of the ectopic
endometrium. Testosterone derivative
(danazol) and gonadotropin-releasing hormone (GnRH)
analog (leuprolide) can be
used to achieve inhibition of the axis.

34. Treatment
Surgery:
Fertility-sparing surgery
Most surgery for endometriosis can be achieved
laparoscopically.
Symptomatic endometriotic chocolate cysts should not just
be drained but the inner cyst lining should be excised to
reduce the risk of recurrence; however, this will be
associated with damage to functional ovarian tissue.
Therefore, when drainage is performed as an adjunct to
fertility treatment, drainage only may be considered.

35. Treatment
Hysterectomy
Hysterectomy with removal of the ovaries and all visible
endometriosis lesions should be considered only in women
who have completed their family and failed to respond to
more conservative treatments.
Estrogen-only hormone replacement therapy (HRT) can be
started immediately following surgery once the patient is
mobile.

36. Thank you.