12 Endometriosis

ENDOMETRIOSIS
DEFINITION
Presence of functioning endometrium
(glands and stroma) in sites other than uterine
mucosa is called endometriosis. It is not a
neoplastic condition, although malignant
transformation is possible.
• These ectopic endometrial tissues may be
found in the myometrium when it is called
endometriosis interna or adenomyosis. More
commonly, however, these tissues are found
at sites other than uterus and are called
endometriosis externa or generally referred
to as endometriosis.
Prevalence
• The real one is due to delayed marriage,
postponement of first conception and adoption
of small family norm.
• The apparent one is due to increased use of
diagnostic laparoscopy as well as hightened
awareness of this disease complex amongst the
gynecologists
• The prevalence is about 10 percent. However,
prevalence is high amongst the infertile women
(30–40%) as based on diagnostic laparoscopy
and laparotomy.
SITES
• Abdominal
• Extra-abdominal
• Remote
Abdominal: It can occur at any site but is usually
confined to the abdominal structures below the
level of umbilicus.
Extra-abdominal: The common sites are
abdominal scar of hysterotomy, cesarean
section, tubectomy and myomectomy,
umbilicus, episiotomy scar, vagina and cervix.
Risk factors for Endometriosis
• Low parity
• Delayed child bearing
• Family history of endometriosis
• Genital flow obstruction
• Environmental toxins(dioxins)
• Molecular defects
– Cytokines
– Tumor necrosis factor α
– Macrophages
– Matrix metalloproteinase
– Interleukin-1
– Vascular endothelial growth factor
PATHOGENESIS
• Pathogenesis still remains unclear and is full of
theories. The principal ones are:
– Retrograde menstruation(SAMPSON’S Theory)
– Coelomic metaplasia: chronic irritation of the
pelvic peritoneum
– Direct implantation: new site implantation
– Lymphatic theory(Halban)
– Vascular Theory: lungs, arms, thighs
– Genetic and immunological factors
Pathology
1. The endometrium in the ectopic site
2. Proliferative changes
3. Cyclic growth and shedding
4. Blood is irritant and causes tissue reaction
5. The cyst enlarges with cyclic
bleeding(chocolate cyst)
6. Dense adhesions in the pelvic structures
• Pelvic endometriosis: Typically, there are
small black dots, the so called ‘powder burns’
seen on the uterosacral ligaments and pouch of
Douglas Fibrosis and scarring in the peritoneum
surrounding the implants is also a typical finding.
• Other subtle appearances are:
– Red flame shaped areas,
– Red polypoid areas,
– Yellow brown patches,
– White peritoneal areas,
– circular peritoneal defects or sub ovarian adhesions.
– These lesions are thought to be more active than the
“powder burn” areas
CLINICAL FEATURES
• Patient Profile: The age is between 30–45. The
patients are mostly nulliparous or have had
one or two children long years prior to
appearance of symptoms
• Infertility, voluntary postponement of first
conception until at a late age
• About 25 percent of patients with endometriosis
have no symptom, being accidentally discovered
either during laparoscopy or laparotomy.
• Depth of penetration is more related to
symptoms rather than the spread. Lesions
penetrating more than 5 mm are responsible for
pain, dysmenorrhea and dyspareunia.
• Abnormal menstruation (20%)
• Infertility (40–60%)
• Dyspareunia (20–40%)
• Chronic Pelvic Pain
• Abdominal Pain
• Urinary—frequency, dysuria, back pain or even
hematuria
• Sigmoid colon and rectum—painful defecation
(dyschezia), diarrhea, constipation, rectal bleeding
or even melena
• Chronic fatigue, perimenstrual symptoms (bowel,
bladder)
• Hemoptysis (rarely), catamenial chest
pain(Spontaneous pneumothorax can cause
sudden chest pain or tightness, difficulty
breathing, shortness of breath and a cough)
• Surgical scars—cyclical pain and bleeding
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Abdominal Examination: A mass may be felt

in the lower abdomen arising from the pelvis
— enlarged chocolate cyst or tubo-ovarian
mass due to endometriotic adhesions. The
mass is tender with restricted mobility
• Pelvic Examination: The expected positive
findings are
– pelvic tenderness nodules in the pouch of
Douglas,
– nodular feel of the uterosacral ligaments,
– fixed retroverted uterus or unilateral or bilateral
adnexal mass of varying sizes
• Speculum examination may reveal bluish
spots in the posterior fornix.
• Rectal or rectovaginal examination is often
helpful to confirm the findings.
• Serum marker CA 125—A moderate elevation
of serum CA 125 is noticed in patients with
severe endometriosis.
• Monocyte Chemotactic Protein (MCP-1) level
is increased in the peritoneal fluid of women
with endometriosis
• Ultrasonography: TVS can detect ovarian
endometriomas. Transvaginal (TVS) and
Endorectal ultrasound are found better for
rectosigmoid endometriosis.
• Magnetic Resonance Imaging (MRI) is a
diagnostic tool: There is a characteristic hyper
intensity on T1 weighted images and a hypo
intensity on T2 weighted images.
• Colonoscopy, rectosigmoidoscopy and
cystoscopy are done when respective organs
are involved.
• Laparoscopy is the gold standard.
Confirmation is done by double puncture
laparoscopy or by laparotomy.
• Biopsy confirmation of excised lesion is ideal
MANAGEMENT
GOALS OF TREATMENT
• To abolish or minimize the symptoms—pelvic
pain and dyspareunia
• To improve the fertility
• To prevent recurrence.
• Determinants of treatment options
– Age of the patient.
– Size and extent of lesions.
– Severity of symptoms.
– Location of disease.
– Desire for fertility.
– Results of previous therapy.
• Administration of non-steroidal anti-
inflammatory drugs or prostaglandin
synthetase inhibiting drugs e.g. Ibuprofen 800–
1200 mg or mefenamic acid 150–600 mg a day is
quite effective.
• Hormonal treatment: The aim of the hormonal
treatment is to induce atrophy of the
endometriotic implants. E.g. Danazol, combined
estrogen and progestogen (oral pill),
progestogens, GnRH analogues(Leuprolide,
Goserelin), Levonorgestrel-releasing-IUCD
SURGICAL MANAGEMENT
• Indications
– Endometriosis with severe symptoms
unresponsive to hormone therapy.
– Severe and deeply infiltrating endometriosis to
correct the distortion of pelvic anatomy.
– Endometriomas of more than 1 cm.
– Surgery may be conservative or definitive
• Laparoscopy is commonly done to destroy
endometriotic lesions by excision or ablation by
electro diatherapy or by laser vaporization.
• Laparoscopic uterosacral nerve ablation (LUNA)
is done when pain is very severe.
• Surgical treatment improves fertility and
symptoms in women with moderate and severe
endometriosis.
COMPLICATIONS
• Endocrinopathy—This may be mostly
responsible for infertility
• Rupture of chocolate cyst Infection of
chocolate cyst
• Obstructive features: –
– Intestinal obstruction
– Ureteral obstruction → hydroureter →
hydronephrosis → renal infection
- Malignancy is rare, the commonest one being
adenoacanthoma

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ENDOMETRIOSIS

• Abdominal Examination: A mass may be felt

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