Professional Documents
Culture Documents
By
Lena Gowharji
Endometriosis
Definition: Benign condition in which
(hormone dependant) endometrial glands
and stroma are present outside the
uterine cavity and wall.
Its importance is due to its
1- Distressing symptomatology
2- Association with infertility
3- Invasive potential (adjacent organs)
4- Difficulty in being diagnosed
Incidence:
*Its estimated that 5-15% of women have
some degree of the disease.
*1/3 of women with chronic pelvic pain have
visualized endometriosis.
*Its been noted in 5-15% of women
undergoing gynaecological laparotomies (an
unexpected finding in 50% of these cases).
Sites of occurrence:
* Most commonly found in the dependant portions of
the pelvis
1- Ovaries (2 out of 3 women with endometriosis)
2- Broad ligament
3- Peritoneal surfaces of the cul-de-sac
(uterosacral ligaments and post. Cervix)
4- Rectovaginal septum
* Quite frequently is the recto-sigmoid colon, appendix,
and vesicouterine fold of the peritoneum involved.
* Laparotomy scars esp. after c section or
myomectomy or after the uterine cavity has been
entered.
Pathology:
* The islands of endometriosis are sensitive to
ovarian hormones.
*Estrogen
proliferation
Macroscopical appearance:
Depends on: site, size, time since
implantation and day of the menstrual cycle.
Colour is a good indicator and is determined
by the vascularity of the lesion, the presence
of fibrosis, the size of the lesion and the
presence of residual sloughed material.
It varies from red, brown, black, white-yellow.
*Newer implants: red, blood filled active
lesions
*Older lesions: scarred with a puckered
appearance.
Other symptoms:
Female reproductive tract:
1- pre and postmenstrual spotting.
2- cyclic pelvic pain.
3- low sacral backpain (especially
premenstually).
4- infertility.
5- diminished amount of menstrual flow.
6- ovulatory pain and mid-cycle vaginal
bleeding.
Signs:
Tenderness on bimanual examination.
Tenderness or nodularity on the posterior
vaginal fornix.
Uterosacral ligament tenderness or
nodularity.
Cystic ovarian enlargement.
Fixation of adnexal structures.
Retroflexed uterus.
Episiotomy or cesarean section scars.
Differential diagnosis
1. Chronic pelvic inflammatory
disease or recurrent acute
salpingitis.
2. Hemorrhagic corpus luteum.
3. Benign or malignant ovarian
neoplasm.
4. Ectopic pregnancy.
Diagnosis
History and examination
Pelvic U/S
Direct visualization of endometriotic
lesions
Pathological examination of biopsy
specimen
Endometriosis in not a clinical diagnosis!
Diagnosis
Suspected in afebrile patient with
the characteristic triad:
1. Pelvic pain
2. Firm, fixed tender adnexal
mass
3. Tender nodularity in cul-de-sac
and uterosacral ligament
Diagnosis
(CA 125)
Frequently elevated in women
with endometriosis
Sensitivity only 20% to 30%
Not used to diagnose
endometriosis
Diagnosis
Definitive diagnosis is generally
made by:
Characteristic gross
Histological findings
Obtained by:
Laproscopy or laprotomy
Endometriosis in not a clinical
diagnosis!
Diagnosis
What do endometriosis lesions look like?
Classic are red, dark brown, dark blue or black
peritoneal implants
chocolate cysts of the ovary
Clear vesicles
White or yellow spots or nodules
Normal appearing peritoneum (microscopic disease)
Later lesions appears as powder burn implants from
thickened or scarred perilesional peritoneum
Diagnosis
Unfortunately, even the most experienced
surgoen may fail to identify endometriosis
implants because:
The older implants may have a very subtle
apperance
The deeper infiltration lesions may not be
visible at the surface
Biopsy of suspecious lesions improves
diagnosis accuracy
Staging
American Society of Reproductive
Medicine (ASRM)
Employs a staging protocol in an
attempt to correlate
Fertility potential with a quantified stage
of endometriosis
Staging
Initially started to be based on:
1- Site of involvement
2- extent of visualized disease
And was modified to include:
Description of the color of the lesions
Percentage of surface involved in each
lesion type
More detailed description of any
endometriosis
Treatment
1.
2.
3.
4.
5.
No treatment
Non-hormonal treatment
Hormonal treatment
Surgical treatment
Radiological treatment
I. No treatment
If small symptom less lesions
Patient observed & examined
every 6 months
II. Non-hormonal
treatment
If small lesions with mild symptoms
Analgesics are given for pain
Prostaglandin inhibitors (naproxen,
ibuprofen) are given for pain and
menorrhagia
III. Hormonal
treatment
Indications:
1. Severe symptoms with small pelvis lesions
2. Recurrence of symptoms after conservative
surgery
3. May be given for a short time (6-12 weeks)
before surgery to make dissection easier
4. After conservative surgery to allow any
residual lesion to regress
5. When operation is contraindicated or
refused by the patient
1. Pseudo pregnancy
Ovulation and menstruation are inhibited
for 9 months (6-18 months) using a
combined OCP or a progestogen alone to
avoid the oestrogenic side effects
A combined contraceptive tablet is given
daily
Oral medroxyprogesterone acetate
(provera tablets) is givin in a dose of 1030 mg daily
Side effects of progestogens: headache,
weight gain, fluid retention, breakthrough
bleeding and depression
2. Pseudo menopause
Danazol:
Side effects:
1.
Androgenic effects: acne, male alopecia, hirsutism, hoarseness of
voice & hypertrophy of clitoris
2.
Hypo-oestrogenic effects: hot flushes, sweating, atrophy of
breasts, atrophic vaginitis, dry vagina, dyspareunia & decreased
libido
3.
Anabolic effects: weight gain & edema
4.
Metabolic effects: impaired glucose tolerance, increased insulin
requirements in diabetic cases, hepatic dysfunction. Blood
pressure may be elevated
5.
CNS: headache, sleep disorders, anxiety, depression & visual
disturbance
6.
GIT: nausea, vomiting & constipation
7.
Muscloskeletal: muscle cramps & swelling of joints
8.
Genitourinary: hematuria
2. Pseudo menopause
GnRH (agonist):
Nafarelin (synarel): intranasally using a
nasal spray, 200 micrograms twice daily
Goserelin (zoladex): 3.6 mg injected SC
every 4 weeks
Triptorelin ( decapeptyl): 3.75 mg injected
IM every 4 weeks
Side effects: hot flushes, dryness of the
vagina, dyspareunia & reduced libido
3. Mifepristone
50 mg/day for 6 months
1. Conservative
surgery
If young patients below 40 years
Pre-sacral neurectomy has been
used to treat severe dysmenorrhea
Minimal to mild disease can be
removed by laser or electrocautery
2. Radical surgery
Patient above 40 years
Treatment is total hysterectomy &
bilateral salpingo-oophorectomy
Endometriosis
Removal of
Endometriosis
Dissection of an Endometrioma
Ovary
Incision
Tube
Removal
Result
V. Radiological
treatment
Induction of artificial menopause by
external pelvic radiation cures the condition
by causing atrophy of endometrial tissue
It is applied only in patients above 40 in
whom operation cant be done as in case
of wide spread pelvic endometriosis (frozen
pelvis) or endometriosis of the rectovaginal
septum which is difficult to excise surgically
Thank you