ENDOMETRIOSIS:Clinical

features, disgnosis and staging of

Endometriosis
Moderator:Dr Nagrathna
Definition

 Endometriosis is defined as the presence of endometrial glands and stroma outside the
uterus.
 Benign condition
 Prevalence: 8-10%
Risk factors

 Menstrual cycle:
1. early menarche
2. heavy menstrual bleeding
3. Short menstrual cycles
 Delayed childbearing
 Nulliparity
 Higher social class
 Obstructive Mullerian anomalies
 Lower body mass index
Pathogenesis: Theories of development of
endometriosis
1. Implantation theory
2. Coelomic metaplasia theory
3. Induction theory
4. Venous and lymphatic dissemination
5. Immunological theory
6. Genetic factors
7. Molecular defects
Clinical features

 Most common in reproductive age group

 Symptoms
1.Pain: severe dysmenorrhea
chronic pelvic pain
pain on defaecation
deep dyspareunia
2. Menstrual abnormalities: heavy menstrual bleeding
premenstrual spotting
3. Infertility
4. Cyclic bowel, bladder symptoms
5.Chronic fatigue
Causes of pain in endometriosis

 Peritoneal inflammation
 Activation of nociceptors
 Nerve irritation with deep infiltration
 Tissue damage
 Local productions of prostaglandins
 Adhesion formation
Causes of infertility in endometriosis

 Ovulatory dysfunction: abnormal folliculogenesis

anovulation
luteal phase defect
luteinized unruptured follicle syndrome
 Immunological alterations: decreased sperm survival
altered immunity
 Peritoneal factors: intraperitoneal inflammation
local production of prostaglandins/cytokines
 Interference with implantation: endometrial dysfunction
 Mechanical factors: anatomical distorsion of tubes
interference with ovum pick up
altered tubal motility
peritubal adhesions
 Interference with coital function: dyspareunia
 Sperm inactivation: phagocytosis by macrophages
inactivation by antibodies
Signs

 Retroverted and fixed uterus

 Tender uterosacral ligaments
 Nodules in Pouch of Douglas
 In case of large endometriomas – pelvic mass may be palpabe abdominally
Clinical diagnosis

 History: Congestive dysmenorrhea, dyspareunia, chronic pelvic pain

 Physical examination:
Large and advanced lesions
1. Abdominal examination: mass arising from the pelvis
located in iliac fossa
tender
not freely mobile
2. Per speculum examination: bluish nodules in posterior fornix
 Per vaginal examination: fixed retroverted uterus
adnexal mass – tender, fixed
tender uterosacral ligaments
 Per rectal examination: tenderness in POD
nodules in POD
Investigations

1. Ultrasound:
 Useful in ovarian endometrioma – cystic mass with internal echoes and hyperechoic foci in
the wall
2. CA-125
3. MRI: endometrioma larger than 1cm
rectovaginal nodules
4. Barium studies: in case of bowel endometriosis
5. Intravenous urography: suspected ureteric involvement
 Laparoscopy: Gold standard
 Visualization of lesions
 Staging the disease
 Biopsy for histology
 Evaluation of the extent of adhesions
 Therapeutic intervention
Classification and staging of endometriosis
THANK YOU