GYNECOLOGY EXIMIUS

ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020
LECTURE OUTLINE • Adolescents with obstructive Mullerian Anomalies
• Incidence • Most commonly in dependent portions of the pelvis
• Pathophysiology
• Clinical presentation Coelomeic Metaplasia Theory
• Diagnosis • Coelomic epithelium ( where mullerian ducts are derived)
• Management retains the ability for multipotential development
o Medical
Coelomic epithelium which
o Surgical
makes up the peritoneal
surface is a multipotential cell,
ENDOMETRIOSIS which when induced by
Endometriosis afflicts women of the reproductive age. It is estrogen and progesterone,
a benign disease yet it is locally infiltrating and a very
undergoes metaplasia and
progressive disease, perplexing obstetrician- gynecologists becomes endometrial cells with
treating it. continued stimulation by
• Presence and growth of endometrial glands and stroma in hormones (estrogen and
an abberant or heterotropic location progesterone) these
endometrial cells proliferate
Incidence just like the endometrium
• 11 % reproductive aged woman
• 5-15 % of laparotomies performed on reproductive aged • Metaplasia occur after an induction phenomenon
women for other indications (Induction substance: combination of menstrual debris
• 33-82 % in women with chronic pelvic pain and estrogen and progesterone) has stimulated the
• 30-45 % in patients with infertility multipotential cell
The incidence of endometriosis has increased over the past • Metaplastic cells transform to endometrial cells
years secondary to increased awareness of mild forms of • Endometriosis in premenarcheal girls
the disease diagnosed by the increasing use of This explains why even in premenarcheal girls, who never
laparoscopy. The exact incidence of the disease is not menstruated (therefore cannot be explained by Sampson’s
known and is only estimated. theory), endometriosis is sometimes found.

Pathophysiology Lymphatic and Vascular Metastasis

1. Retrograde menstruation (Sampson’s)
2. Coelomic metaplasia
3. Lymphatic and vascular metastases
4. Iatrogenic dissemination
5. Immunologic Changes
6. Genetic Predisposition
7. Hormonal Influences
8. Environmental Factors
There are several theories to explain the pathogenesis of
Endometriosis. However, no single theory explains all the
manifestations of the disease. Iatrogenic Dissemination
Retrograde Menstruation (Sampson’s Theory)
there is increasing evidence that environmental factors
plays a role specially dioxin and other endocrine disruptors
• Most popular theory
• Reflux of menstrual blood and endometrial cells at the
tubal ostia during menstruation attach to the pelvic
peritoneum and under hormonal influence grow as
homologous grafts
• Endometrium transplanted via lymphatic channels and the
vascular system to different parts of the body
• Endometriosis has been observed in the pelvic lymph
nodes of approximately 30 % of women
• Endometriosis of the forearm, thigh, and multiple lesions
in the lungs and nose
Hematogenous dissemination of the endometrium is the
best theory to explain the presence of endometriosis in
rare and remote sites.
• Endometrial glands and stroma are implanted during the
performance of an operation
Examples:
endometriosis at the
anterior abdominal wall
or episiotomy scar

Immunologic Changes
• Primary immunologic change: alteration in the function of
the peritoneal macrophages in the peritoneal fluids of the
patients with endometriosis
More Enhance
Secrete
peritoneal development
multiple
macrophages of
growth factors
that are larger endometriosis
and cytokines
and hyperactive

TRANSCRIBERS CABALZA, JKB. 1

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020
One of the observations of experts is that some women Pathology: Ovary
with retrograde menstruation develop endometriosis while Endometrioma/ Endometriotic Cysts:
majority do not. Investigations suggested that changes in • Chocolate Cyst
the immune function are directly related to the
pathogenesis of endometriosis.

Genetic Predisposition
• 7x increase incidence of endometriosis in relatives of
women with the disease
• 1/10 women with severe endometriosis will have a sister
or mother with clinical manifestations of the disease
• Women who have a family history of endometriosis are
likely to develop the disease earlier in life and to have
more advanced disease
• Several candidate gene and gene products are abberantly
expressed in patients with endometriosis
Several studies have shown clustering of endometriosis in
Peritoneal Endometriosis
families like mother and daughter
• Gross Appearance
o powder burn, puckered black lesions
o vascularized glandular papules
o vesicular lesions
o red, flamelike
o petechial peritoneum
o discolored areas
The gross appearance of the implant depends on the site,
activity, relationship to the day of the menstrual cycle, and
chronicity of the area involved.
• Small bleb like appearance

Endometriosis most commonly affects the most dependent

portion of the pelvis
Common sites Rare Sites
Ovaries Umbilicus
Pelvic peritoneum Episiotomy scar
Ligaments of the uterus Bladder
Pelvic lymph nodes – 30% Kidney
Rectosigmoid – 10 to 15% Lungs
Appendix Arms and legs
Vagina Nasal mucosa
Cervix Spinal column
Fallopian tubes

Small, bleblike implants that are raised above the

surrounding tissues, less than 1 cm in diameter are new
lesions.
Very subtle. Represents the earliest form of the disease
• Red Blood-filled lesions
• red, flamelike
• petechial peritoneum
Red, blood-filled lesions are the most active phase of the
disease.

TRANSCRIBERS CABALZA, JKB. 2

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020
The associated adhesions may be minimal or extensive,
filmy or dense, and avascular or vascular

• powder burn, puckered black lesions

These lesions will later on progress to? Scripted na tanong
to ni Doc bale check nyo na lang sagot sa book. Powder Minimal filmy adhesions
burn lesions are the older lesions and usually are the deep
infiltrating lesions

• White lesions/ scar

The older lesions are white, have more intense scarring,
and are usually puckered or retracted from the
surrounding tissue.
White or mixed colored lesions are more likely to provide
histologic confirmation of endometriosis.
The progression from red to white lesions also seems to
Minimal-mild form of the disease with normal anatomy of
correlate with age.
the reproductive organs ----- severe form of the disease
with the cul de sac obliterated due to dense adhesions

Three Cardinal Histologic Features and Symptoms

1. Ectopic endometrial glands

2. Ectopic endometrial stroma
3. Hemorrhage into the
adjacent tissue

Endometriosis: A Disease of Clinical Contrasts

Characteristics Contrasts
Benign Disease Locally invasive
Widespread disseminated foci
Proliferates in pelvic lymph
nodes
Minimal Disease Severe pain
Many large endometriomas Asymptomatic patient
Pathology: Adhesions Cyclic hormones cause growth Continuous hormone reverse
the growth pattern

The symptomatology does not correspond to the severity

of the disease.
• Classic Symptoms:
o Cyclic pelvic pain
o Infertility

• Other symptoms:
o Secondary dysmenorrhea
o Dyspareunia
o Abnormal bleeding

TRANSCRIBERS CABALZA, JKB. 3

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020
o Urinary symptoms: Diagnosis
§ Urinary frequency History and Physical Examination
§ Hematuria • Cyclic or chronic pelvic pain, deep dyspareunia presenting
§ Dysuria with subfertility
o GI symptoms: • Rectovaginal examination performed during the
§ Cyclic abdominal pain menstrual phase (D1-D2) may aid in the diagnosis as it is
§ Intermittent constipation the time of maximal swelling and tenderness in the areas
§ Diarrhea of endometriosis
§ Dyschezia o Pelvic tenderness
It is important to emphasize that 1/3 women with o Fixed retroverted uterus
endometriosis are asymptomatic and are diagnosed o Tender and thickened uterosacral ligaments
incidentally during operation due to other causes. o Enlarged ovaries

Symptoms: Pain
• The cyclic pelvic pain is related to the sequential swelling History and PE :
and the extravasation of blood and menstrual debris into
the surrounding tissue It should be suspected in patients
• Mechanism of Pain: with cyclic or chronic pelvic pain
o Production of substances like prostaglandins, and infertility or dyspareunia.
growth factors and cytokines by macrophages Rectovaginal examination
o Direct and indirect effects of active bleeding examination should be done and
from the implants preferably during the menstrual
o Irritation and direct invasion of nerves by cycle to detect nodulations and
infiltrating endometriotic implants scarring in the USL which
The chemical mediators of this intense sterile inflammation suggests the presence of
and pain are believed to be prostaglandins and cytokines endometriosis..

Symptoms: Secondary Dysmenorrhea

• varies from a dull ache to severe pelvic pain Diagnosis: Ultrasound
• unilateral or bilateral radiating to the lower back, legs, and • detect endometriotic cysts but not peritoneal
groin endometriosis
• Pelvic heaviness or a perception of their internal organs o Unilocular cyst with low to medium level echoes
being swollen within
• Pain may last for many days, including several days before
and after the menstrual flow.

Symptoms: Dyspareunia
• pain deep in the pelvis during intercourse
• Due to immobility of the pelvic organs during coital activity
or direct pressure on areas of endometriosis in the
uterosacral ligaments or the cul-de-sac.
• The acute pain may continue for several hours following
intercourse.
Diagnosis: Laparoscopy
Signs • “Gold Standard” in diagnosis
• Classic Sign: • Offers an addititional benefit of treatment at the time of
o Fixed, retroverted uterus w/ scarring & diagnosis
tenderness posterior to the uterus • Visual Inspection with histologic confirmation is the
• Others: definitive means to establish the diagnosis of pelvic
o nodularity of uterosacral ligaments & cul de sac endometriosis.
o ovaries may be enlarged & tender and often Although laparoscopy is the gold
fixed to the broad ligament or lateral pelvic wall standard in diagnosisng
• Nodularity of the uterosacral ligaments and cul-de-sac may endomet, its natiure and extent
be palpated on rectovaginal examination in approximately of the disease, this is not always
one third of women with the disease. possible specially in young
• Advanced cases have nulliparous pxs…
o extensive scarring and If we ruled out the possibily of
o narrowing of the posterior vaginal fornix infection and malignancy, and
highly suspect endometriois by
history and PE, then it is prudent
to do trial of medical
management for 3 months..

TRANSCRIBERS CABALZA, JKB. 4

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020

Diagnosis: CT Scan or MRI GnRH Agonist

• Not a practical modality for endometriosis diagnosis • Leuprolide acetate (Lupron, injectable)
o 3.75 mg intramuscularly once per month or
Diagnosis: CA 125 11.25 mg depot injection every 3 months
• Has NO value in the diagnosis of endometriosis • Nafarelin acetate (Synarel, intranasal)
o one spray (200 mg) in one nostril in the morning
Management and one spray (200 mg) in the other nostril in the
• Primary short term goals evening up to a maximum of 800 mg daily
o relief of pain • Goserelin acetate (Zoladex, subcutaneous implant)
o promotion of fertility o 3.6 mg every 28 days in a biodegradable
• Primary long term goal subcutaneous
o prevent progression or recurrence of disease • MOA: Down regulates and desensitizes pituitary gland to
• Choice of therapy, depends on patient's age, her future produce extremely low levels of FSH & LH ----- Low
reproductive plans, location and extent of the disease, the estrogen and progesterone
severity of symptoms, and associated pelvic pathology. • “medical oophorectomy”
• Primary goal of the hormonal treatment: Induction of • No effect on sex-hormone binding globulin
amenorrhea • Side effects:
o hot flushes,
o vaginal dryness
Recurrent bleeding in the ectopic implants is one of the o insomnia
most important pathophysiologic processes to interrupt o decrease bone density
• Medical: • Advantage: better patient compliance
o NSAIDS Can only be used for 6 months for its Side effects to be
o Danazol reversible after discontinuation.
o GnRH Agonist
o Combined oral contraceptive pills Combined Oral Contraceptive Pills
o Progestins: • Produce amenorrhea
§ Medroxyprogesterone • “pseudopregnancy”
§ Depomedroxyprogesterone • Continuous low dose monophasic OCP
§ Levonorgestrel Intrauterine system As in other oral hormonal regimen, amenorrhea is the
o Aromatase inhibitors desired endpoint continuous daily oral contraceptives for 6
• Surgical: to 12 months beginning on the third day of the patient's
o Laparotomy (Open) period
o Laparoscopy (Minimally invasive) • Others:
Induction of amenorrhea is the primary goal of the o Aromatase inhibitors
hormonal treatment because recurrent bleeding in the o Medroxyprogesterone
ectopic implants is one of the most important § 30mg/day
pathophysiologic processes to interrupt o Depomedroxyprogesterone
§ 150mg IM every 3 months- 200 mg
Medical every month
Danazol o Levonorgestrel-containing Intrauterine device
• Dosage: 400-800mg/day for 6 months system
• hypoestrogenic & hyperandrogenic As in other oral hormonal regimen, the amenorrhea is the
• MOA: binds to androgen and progesterone receptors and desired endpoint
sex hormone-binding globulin.
Rarely used now because of its side-effects that does not Surgery
resolve after discontinuation.. Main Role:
• Adverse effects: There has been a shift in the management of
o menopausal hot flushes endometriosis especially in the presence of ART
o atrophic vaginitis
o emotional lability Previous Years Present
o weight gain Large endometriomas >3-4 cms Provide symptomatic relief of
o fluid retention pain
o migraine headaches Improve Fertility Outcomes
o deepening of voice Failed medical management
Adverse affects of danazol is irreversible Acute rupture endometriomas
• The recommended doses of Danazol for the treatment of
endometriosis have substantial androgenic and Conservative Surgery
hypoestrogenic side effects that limit the clinical utility of • resection or destruction of endometrial implants, lysis of
the drug adhesions, and attempts to restore normal pelvic anatomy

TRANSCRIBERS CABALZA, JKB. 5

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020
Definitive Surgery Standard Criterion for the diagnosis of
• removal of both ovaries, the uterus, and all visible ectopic Adenomyosis
foci of endometriosis
• Address 3 main categories of the lesion : Endometrial glands and stroma more
o Superficial than one low-powered field (2.5 mm)
o Endometrioma from the basalis layer of the
o DIE endometrium
Laparoscopic Excision
• Is currently the “GOLD STANDARD” approach for the
management of endometriosis
Manifestation
Minimally Invasive Surgery • Asymptomatic
• Is preferred: • Parous, more than 35 years old
o Laparoscopy • Classic Symptom:
o Robotic surgery o Secondary dysmenorhhea
• Advantages: o HMB (Menorrhagia)
o Improved visualization • Sign: globularly enlarged uterus, 2-3x normal size
o Shorter recovery period
o Decrease blood loss
o Decreased risk of complication
Minimally invasive Surgery has largely replaced the need
to open surgery

Endometriosis- Associated Infertility

• Surgical therapy- preferred approach
• Surgical removal of all endometriotic lesion is the only
Adenomyosis Myoma
treatment that improves spontaneous conception rates in
infertile patients with endometriosis • The diagnosis of adenomyosis is usually confirmed
following histologic examination of the hysterectomy
• Pregnancy rates after surgery:
specimen
o Laparoscopy= 54-66%
o Laparotomy (open) = 36-45%
Diagnosis
There is no evidence that medical therapy can improve
pregnancy rates of patients with endometriosis associated • Transvaginal Examination (Left photo)
infertility • MRI (Right photo)
Hidden powerpoint slide to ni Doc guys, pero nilagay ko na
lang din.

Adenomyosis
• Growth of endometrial glands & stroma within the
myometrium to a depth of 2.5 mm from the basalis layer
Currently not considered a variant of endometrios

Pathology
• Cut surface protrudes convexly and has a spongy Treatment
appearance • There is no satisfactory proven medical treatment for
• Cut surface is darker than the white cut section of a adenomyosis
myoma o GNRH Agonists
• There is NO distinct cleavage plane around focal o Cyclic hormones
adenomyoma compared to myoma o Prostaglandin inhibitors
• Hysterectomy
o definitive treatment if this therapy is appropriate
for the woman's age, parity, and plans for future
reproduction

TRANSCRIBERS CABALZA, JKB. 6

 GYNECOLOGY EXIMIUS
ENDOMETRIOSIS 2021
Jacqueline Banatao- Pua, MD, FPOGS, FPSREI, FP May 2020

TRANSCRIBERS CABALZA, JKB. 7