Endometriosis is an estrogen-dependent disease where endometrial tissue grows outside the uterus, most commonly on the pelvic peritoneum and ovaries. It affects 5-10% of women and is a common cause of pelvic pain and infertility. While the exact cause is unknown, theories include retrograde menstruation through the fallopian tubes and genetic or immunological factors. Diagnosis involves laparoscopy to visualize lesions, and ultrasound or MRI may also help. Treatment depends on symptoms but may include pain medications, hormonal therapy, or surgery to remove growths or the ovaries/uterus. Surgical treatment can help fertility in mild-moderate cases.

1. Endometriosis

2. Introduction
 Definition :
estrogen dependent disease in the reproductive age women with
presence of endometrial glands and stroma outside of the normal
location
 Locations :
most commonly found on the pelvic peritoneum, on the ovaries
(endometrioma), rectovaginal septum, and ureter, and rarely in the
bladder, pericardium, pleura and abdominal wall cs scar
 Incidence :
• 5–10% of women of reproductive age
• It is found in at least one-third of women undergoing a diagnostic
laparoscopy for pelvic pain or infertility

3. Etiology
Many theories may explain it :
 Sampson’s implantation theory
 Meyer’s ‘coelomic metaplasia’ theory
 Genetic and immunological factors
 Vascular and lymphatic spread

4. Sampson’s implantation theory
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
Support the theory :
Endometriosis in Genital tract flow obstruction cases
Endometriosis in cs scar

5. Meyer’s ‘coelomic metaplasia’ theory
Dedifferentiation of peritoneal cells lining the Mullerian duct
back to their primitive origin, which then transform into
endometrial cells

6. Genetic and immunological factors
There appears to be an increased incidence in first-degree
relatives of patients with the disorder and racial differences,
with increased incidence among oriental women and a low
prevalence in women of Afro-Caribbean origin

7. Vascular and lymphatic spread
explains the rare findings of endometriosis in sites
outside the peritoneal cavity, such as the lung

8. Presentation
 Pelvic pain
 Infertility
 Asymptomatic (incidental finding )
 Abnormal bleeding

9. Symptoms

10. Diagnosis
physical examination
 thickening or nodularity of the uterosacral ligament
 tenderness in the pouch of Douglas
 an adnexal mass or a fixed retroverted uterus
 Bluish nodules in the vagina or the cervix
 Bluish nodule or tender mass on superficial palpation of the abdomen

11. Diagnosis
Laparoscopy
 The gold standard
 Visualization of red, puckered, black ‘matchstick’ or appear white and fibrous
 Benefit of biopsy for histopathology confirmation

12. Diagnosis
transvaginal ultrasound
 Useful in ovarian endometrioma as ground glass appearance cyst and in
rectal endometriosis

13. Other diagnostic tools
 MRI can detect lesions >5 mm in size, particularly in deep tissues, for example
the rectovaginal septum
 Biomarkers as CA125 increased but not specific

14. Management of pelvic pain
 Medical :
NSAID
OCP
Progesterone (oral , injectables , levenogestrel IUS )
aromatase inhibitors (letrazole , anastrazole )
Gestrinone (androgen agonist )
Danazol
Gonadotropin releasing hormone agonist
Surgical :
Coagulation of endometriotic spots
Endometrioma excision
Hysterectomy and oophorectomy

15. Infertility and endometriosis
 30% and 40% of patients with endometriosis complain of difficulty in conceiving
 Medical therapy shouldn’t be used for infertility (OCP , progesterone …. etc)
 Surgical treatment by coagulation of spots in mild to moderate cases improves
spontaneous fertility
 In more sever cases , surgery if possible with IVF
 Endometrioma excision if :
 Symptomatic
 Interfere with ovum pick up during IVF process (more than 3 cm )
Removal of ovarian endometrioma for the aim of fertility is not justified due to the
risk of decrease ovarian reserve