2. Pelvic
Endometriomas
By
DR. SALAH ROSHDY (MD)
Professor of OB/GYN
3. Introduction
• Endometriomas of the ovary were
described by Samspan as
endometrial cysts almost 80 years
ago.
• Endometriomas may arise by
invagination of surface
endometriosis into ovarian tissue .
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4. • The endometrial glands and stroma
then grow & proliferate inside the
ovary, leading to development of the
cyst.
• The size of the cyst depend on
degree of growth & proliferation of
endometrial tissue & on
haemorrhagic products that are
shed into the cyst
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5. Definition
• Endometriomas are “nodules” or
tumours of endometrial tissue are
found mainly in peritoneum lining
of pelvis & ovaries which appear
either in the form of small
superficial islands or in the form
of epithelial (chocolate cyst).
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6. Epidemiology
• The exact incidence of endometriosis is
not known because this disease can be
only diagnosed by visualization during
surgical procedure.
• Its prevalence are probably in the range
of 5% of women of reproductive age with
peak incidence in between 25-30y.
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7. • The endometriosis is found in
• 25-40% of women with infertility &
• in 2-5% of the general population.
• 12-32% of women in childbearing period
undergoing laparoscopy because of
pelvic pain.
• 1% of women having gynacological
operation for any reason.
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9. Aetiology & Pathogenesis
1) Endometrial implantation
A - retrograde menstruation
B - lymphatic & vascular theory
C - mechanical theory
2) In situ development
A - Coelomic metaplasia theory
B - induction theory
3) Immunological theory
4) Composite theory
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10. Hypothesis for aetiology of
endometriosis
1. Cell adhesion.
Cell adhesion molecules especially
integrin & cadherin are the main mediator
of intercellular & cell matrix adhesions, and
may be important for the adhesion of
endometrial tissue to the pelvic wall.
2. Proteolytic enzymes.
After adhesion of endometrial cells to the
pelvic wall successful implantation of tissue
require digestion of extra-cellular matrix.
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11. 3) Angiogenesis ,growth factor &
tumour suppressor gene.
Angiogenesis is complex process
involving proliferation, migration &
extension of endothelial cells
,adherence of these cells to extra-
cellular matrix & formation of new
lumen.
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12. 4) Hormonal factor.
Oestrogen is required for the growth
of endometriotic lesion although the
exact mechanism is unknown, it is
likely via a complex pathway of up-
regulation of cytokines and growth
factors such as VEGF & IL8
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13. Pathology
1-Growth pathology.
The ovary most commonly affected
pelvic structure, followed by posterior
broad lig., uterosacral lig., posterior cul-
de-sac, peritoneum, fallopian tubes &
bowel.
Endometriomas occur bilaterally in
one third to one half of the patient & may
become relatively large (10-15).
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14. Pathology - cont.
2- Microscopic picture.
The pathological diagnosis is
confirmed when 2 of the following 3
feature are identified:-
• Endometrial glands
• Stroma
• Hemosiderin pigment
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15. Growth specimen of endometrioma
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16. Clinical Presentation
Symptoms Signs
1. Pelvic pain 1. Local tenderness in
2. infertility cul-de-sac or
3. Hypermenorrhea uterosacral ligament
4. Premenstrual staining 2. Adnexal enlargemen
or tenderness
5. Dysparonia
3. Pelvic masses
6. Supra pubic pain
7. Dysuria
8. Haematuria
9. Dyschezia
10. Lower back pain
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17. Classification
Endometrioma size (1-2cm) & contain
dark fluid. They develop from surface
Type I endometrial implants.
Microscopically, endometrial tissue
seen in all of them.
Endometriomas are hemorrhagic cyst
, the cyst wall is separated easily from
ovarian tissue. Endometrial implants
are superficial and adjacent to
Type II A
hemorrhagic cyst which is either
follicular or luteal in origin ,
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no endometrial lining 17
18. Type The cyst lining is separated easily from
II B ovarian capsule & stroma except near
endometrial implant.
Type the surface endometrial implant penetrate
II C deeply into the cyst wall, type IIB,C
endometriomas are large & associated with
peri-ovarian adhesion.
Type Ovarian endometrial cyst at least 3 cm in
III & diameter, the other characters are similar to
IV stage III &IV endometriosis.
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19. Diagnosis of pelvic
endometriomas
Physical examination
Imaging studies
A- Ultrasonography
Trans-vaginal sonography is the most
commonly indicated test to diagnose
endometriomas. Accuracy in diagnosis varies
with experience of the radiologist.
B- MRI.
It appear most useful for the detection
of endometriomas, with diagnostic sensitivity
similar to ultrasound.
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24. C-Computerized tomography (CT).
Rarely used due to the widely differing
appearance of the lesion .
D-Optical coherence tomography (OCT).
It is recently developed real time imaging
technology, it is analogous to ultrasound
measuring the intensity of back – reflected
infrared light rather than acoustic waves, the
ability to obtain an optical biopsy.a high
resolution cross sectional image of tissue in-
situ.
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25. Laparoscopy
• The gold standard for definitive diagnosis of
endometriomosis is laparoscopy.
• Typical picture is powder burn lesion & 20
different morphological appearance (fibrotic
white, brown ,black, clear vesicle, flat red
lesion, yellow brown patches, peritoneal
pockets & adhesion.).
• endometriomas ( grape ,grape fruit &
chocolate cyst).
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37. Transvaginal hydro-laparoscopy (THL).
• It has become available as an office technique
using 3-mm needle system introduced through
the posterior fornix & saline as distention
medium, the technique is more accurate than
laparoscopy in the early detection of
endometriotic lesion.
Serum CA-125.
• Level of CA-125 decrease following treatment
& it may prove to be a reliable parameter for
clinical course follow up.
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38. Histopathological diagnosis.
Thermo-colour test.
It is diagnostically accurate in in
85%of cases. The test best applied at
the beginning of the cycle. Here, healthy
peritoneum become white at 100 c while
pale red endometriotic implants become
dark brown or black owing to its
haemosidirin content.
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39. Treatment of Pelvic
Endometriomas
Aim of treatment
• Destroy or remove most of implants.
• Restore the normal anatomy.
• Prevent or delay progression.
• Relieve the patient symptoms.
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40. 1 - Medical treatment
1. It is used conventionally in treatment of
endometriosis however endometriomas are
invariably unresponsive to drug therapy .
2. There is rational to use post operative
GnRh analogue treatment to .
• Accomplish complete resection of lesions
that can not be surgically removed .
• Treat microscopic foci .
• Prevent iatrogenic dissemination of
endometriotic cell.
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41. 2 - Conservative surgical Procedure
It is frequently the treatment of choice for
symptomatic endometriomas
A. Conservative Laparoscopic Procedure
Laparoscopy is the first choice
technique in the treatment of
endometriomas because of
low morbidity, high tolerance,
faster patient recovery ,short hospital stay
& reduced cost.
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42. • Excision of the cyst
(endometriomectomy) by capsular
stripping & laser vaporization or
excision diathermy.
• Incision & drainage without removal of
the cyst.
• Fenestration & coagulation.
• Laser or cautery ablation of the cyst
wall
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45. B. Conservative Laparotomy
• The traditional surgical approach to
endometriomas has been to perform a
laparotomy & microsurgery, however
this strategy has been changed &
laparotomy should no longer the
surgical technique of the 1st choice.
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46. • Although the pregnancy rate & cyst
recurrence & adhesion were found to be
comparable between the two procedure,
yet blood loss at operation, the length of
hospital stay and the recovery time of
the patient were significantly lower in
laparoscopic group.
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47. 3 - Sclerotherapy
• The technique involve needle aspiration of
the liquid content of the cyst, followed by
injection of 4-5% tetracyclin into the cyst
cavity. Treatment results in disappearance
of the lesion within 6-8 w, in more than 75%
of cases
• It is a safe & effective alternative to surgery
for definitive treatment of recurrent cases &
in select group of the patient planned to
undergo IVF.
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48. 4 - Radical treatment
• Hysterectomy & bilateral salpingo –
oophorectomy are indicated in patient
with severe symptoms ¬
responding to other measures & are
not interested in pregnancy.
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49. 5 - Immunotherapy
• It is a very new approach using
tumour vaccine RESAN, which
trigger T-cell immune response
against endometriosis, showing
promising results.
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