Endometriosis

Labeeb Pc

102

Topics to be dicussed…

Introduction

Pathogenesis

Risk factors

Classification

Symptoms

Physical examination

Differential diagnosis

Investigations

Staging

Introduction

Presence of endometrial glands & stroma

outside the uterus

Benign

Incidence – 10%

Pathogenesis

1. Implantation Theory ( Sampson’s)

2. Coelomic metaplasia Theory ( Meyer )

3. Lymphatic & Vascular Metastatic Theory ( Halban )

4. Hormonal - estrogen

5. Genetic

6. Immunological

Implantation Theory

(Sampson’s)

Retrograde menstruation

Common in obstructive Mullerian anomalies,

cryptomenorrohea.

Women with short & heavy menstrual cycles

Scar endometriosis

Dependant portion of pelvis

Cytokines - Adhesion to peritoneal surface

MMP - Invasion

VEGF-A - Angiogenesis

Growth factors - Growth

Estrogen - Proliferative change

Prostaglandin - inflammation, pain

Sites

Common – ovaries, pouch of Douglas,

uterosacral ligaments, Broad ligaments, fallopian

tubes, uterovesical fold, round ligament, appendix ,

vagina

Rectovaginal septum, sigmoid colon, cecum,

umbilicus, abdominal scars, tubal stumps

Risk Factors

1. Menstrual cycle

Early menarche

Heavy menstrual bleeding

Short menstrual cycles

2. Delayed childbearing

3. Parity

Low parity, nulliparous

4. High social class

5. First degree relatives

6. Low BMI

7. Obstructive Mullerian anomalies

8. Environmental

Classification

1. Superficial endometriosis

2. Ovarian endometriosis

3. Deep infiltrating endometriosis

Superficial Endometriosis( Peritoneal)

Dependent portion of pelvis.

Most common – surface of ovaries.

Pelvic peritoneum, pouch of Douglas, uterosacral ligaments,

Broad ligaments.

Appearance –

Early - Papular, vesicular

Hemorrhagic - red, flame shaped

Powder burn - puckered, blue- black - inactive old lesions

Fibrotic - white

Peritoneal cavity – yellowish brown fluid

Cannot be palpated on clinical examination

Difficult to visualise on imaging and diagnosis by laparoscopy

Ovarian Endometriosis ( Ovarian Endometrioma)

Inversion & invagination of ovarian cortex , with superficial

endometriotic deposits.

Adhesion of ovary to post. Peritoneum

Chocolate Cysts.

Cyst wall white or yellow.

<12cm

Histology- pseudoxanthoma cells - macrophages , are brown.

Deep Infiltrating Endometriosis( Posterior Pelvic Endometriosis )

Lesion extends >5mm beneath peritoneum.

Usually in rectovaginal space,

also uterosacral ligaments, cervix , bowel or ureters.

Can be felt on pelvic & per rectum examination – tender

induration & nodularity

Can be visualised on imaging.

Extrapelvic Endometriosis

Urinary tract

GI tract

Surgical scars

Pulmonary

Symptoms

Classic symptoms – Dysmenorrhoea, Dyspareunia, deep

seated pelvic pain.

Menstrual – menorrhagia, Premenstrual spotting

Infertility

Cyclical bowel & bladder symptoms

Scar endometriosis – cyclical pain

Cyclical haemoptysis & haemothorax

Causes of infertility

Ovulatory dysfunction

Anovulation

Luteal phase defect

Luteinised unruptured follicle syndrome

Immunological alteration

Mechanical factors

Dyspareunia

Endometrial dysfunction

Sperm inactivation

Physical Examination

1. Abdominal examination

ovarian mass – tender, fixed, in iliac fossa

2. Per speculum examination

Vaginal lesions – bluish puckered spots

3. Pelvic examination

Fixed retroverted uterus

Adnexal mass

Tender uterosacral ligaments

4. Per rectal examination

Differential Diagnosis

1. Chronic PID

2. Uterine myomas

3. Ovarian malignant tumour

4. Rectal Ca

5. a/c abdominal catastrophe

6. c/c pelvic congestion syndrome

Investigations

1. USG

Useful in ovarian endometrioma.

Ovarian mass- Cysic mass, low level internal echoes

2. MRI

Useful in ovarian endometrioma

Endometrioma > 3cm

Rectovaginal nodules

3. Doppler ultrasound

4. CA 125 > 35u/ml

Abdominal TB, PID, ovarian tumour, c/c liver disease, menstruation,

5. Barium studies

6. Intravenous urography

Laparoscopy

Gold standard for diagnosis.

Visualisation of lesions

Staging of disease

Biopsy for histology

Evaluate extend of adhesions

Therapeutic

Classification & Staging

American Society For Reproductive Medicine ( ASRM )

Based on - appearance, size, depth, presence & extent of

adnexal adhesions and degree of obliteration of pouch of

Douglas

To describe extent of disease, plan management.

Drawback – doesn’t take into account pain or inferitlity

STAGE 1(MINIMAL) -SCORE 1-5

STAGE 2 (MILD) -SCORE 6-15

STAGE 3(MODERATE) -SCORE 16-40

STAGE 4(SEVERE) - SCORE >40