ENDOMETRIOSIS

Def: Presence of endometrial glands and stroma outside the endometrial cavity and walls.
Deposits proliferate during the menstrual cycle, break down & bleed, causing local inflammatory reaction.
Fibrosis & distortion of the tissue affected with dense scarring.
Benign.
EPIDEMIOLOGY
OVERVIEW
SITES
More commonly in the dependant
Disease of reproductive age
Hormone dependant
part of the pelvis
group
Responds to estrogen
Ovaries (2/3 of women)
Affect 5-15% of women
Regress after menopause, oopherectomy
Broad ligament
Diagnosed in 20-30% of
and during pregnancy
Peritoneal surface of Cul-de-sac
women investigated for
ETIOLOGY
and uterosacral ligaments
infertility
Unknown
Rectovaginal septum

More in women whose first

Theories
Rectosigmoid colon
degree relative have the
Retrograde menstruation
Distant and laparatomy scars
disease
Coelomic epithelium transformation
Often diagnosed incidentally
Lymphatic and vascular spread
High social class women in
Genetic and immunologic factors
their thirties and infertile!
Can be diagnosed in any type
of women and all age groups
PATHOLOGY
HISTOPATHOLOGY
Gross
Active endometrial glands and stroma
Hemorrhagic vesicle
Free
Blood filled cystic lesions
Papule and later nodule
Fibrosis with glands only no stroma
Enclosed
Adhesion formation
White nodules or flattened fibrotic scar
Healed
Ovarian endometrioma is an enclosed hemorrhagic cyst
of variable sizes

SYMPTOMS
According to site
No relation between extent of the disease and severity of the symptoms
Often discovered incidentally
FEMALE
Dysmenorrhea, Lower abdominal and pelvic pain, Dyspareunia, Accident to endometriotic cyst,
REPRODUCTIVE
Low back pain, Infertility, Menstrual irregularity
TRACT
URINARY TRACT
Cyclical haematuria / dysuria, Ureteric obstruction
GIT
Dyschezia, Cyclical rectal bleeding, Intestinal obstruction
SURGICAL SCAR &
Cyclical pain and bleeding
UMBILICUS
LUNGS
Cyclical haemoptysis, Haemopneumothorax
CLNICAL FINDINGS
INVESTIGATIONS
DDx
DIAGNOSIS
Often Negative
Ca 125 often
All causes of chronic pelvic
Direct visualization of the
elevated
pain
lesion
Suggested by
Laparascopy
Thickening and nodularity Ultrasonography for
Acute conditions
Laparatomy
of uterosacral L.
ovarian cyst
Ectopic pregnancy
Tenderness in POD
MRI
Acute PID
Histopathology to confirm
Ovarian mass/ masses
Complicated ovarian cyst
the diagnosis
Fixed retroverted uterus
Acute appendicitis and
Tender nodule in the
other surgical
cervix, umbilicus or scar
emergencies

TREATMENT
NSAIDS
PSEUDOPREGNANCY

- Combined OCP continuous

- Cyclical ?? of limited value
Side effect
- Synthetic progestogens: Medroxyprogesterone acetate and dydrogesterone high doses continuous
Side effect
- Levonorgestrel-releasing system reduces dysmenorrhoea and regress POD implants
PSEUDO Danazol androgen derivative 6-9 months
MENOPAUSE
Gestrinone, androgen derivative
Both drugs have androgenic side effects
GnRH agonists - Menopausal symptoms, Osteoporosis
? Add back therapy
SURGERY
CONSERVATIVE
Young patient, women seeking pregnancy, cysts >3cm in diameter
Surgical excision, Laser
HYSTERECTOMY &
Radical/Definitive surgery
BSO
FACTORS TO CHOOSE TREATMENT
ENDOMETRIOSIS & INFERTILITY
Certainty of diagnosis
Ovarian function
Severity of symptoms
Tubal function
Extent of the disease
Coital function
Fertility
Sperm function
Age
Early pregnancy failure
Damage to other organs

ADENOMYOSIS
Endometrial glands deep within the myometrium
Unknown etiology
Different type of patient and presentation
RISK FACTORS
TREATMENT
Multiparous women
Induce amenorrhea - sx recur once treatment is stopped.
Late thirties or early forties
Hysterectomy is the only definitive treatment
Severe spasmodic dysmenorrhea
Menorrhagia
Bulky uterus
Diagnosis often histological on examination of
hysterectomy sample