Introduction
- Common gynecological problem
- Affect reproductive age group
- Difficult to treat
- Adolescents girls – mullaerian anomaly
- Postmenopausal - HRT
DEFINITION
Presence of viable Endometrial tissue
(Glands surrounded by stroma)
outside the uterine cavity.
Sites of endometriosis
Pelvic and extra pelvic
Endometriosis of POD-(pouch of douglas)
Endometriosis of peritoneum
Ruptured endometriotic cyst
Ectopic Endometrial tissue
Tissue Contents
Endometrial Glands
Endometrial Stroma surrounding the glands
Character
Respond to hormonal stimulation
Benign tissue that invades other surrounding tissues
Menstruation within the ectopic endometrial tissue
Inflammatory response
Fibrosis
Endometriosis Theories
- Implantation theory (sampson)
- Coelomic metaplasia theory
- Scar endometriosis
Other factors
- Immunological
- Genetic
- Hormonal
Samson’s Implantation theory:
- Reflux of endometrial tissue
- Endometriosis in girls with cryptomenorrhoea
Scar endometriosis-following
- Classical Caesarean section
- Hysterotomy
- Myomectomy.
- Episiotomy
Unusual sites:
- Umbilicus,
- Ureters,
- Lung,
- Pleura,
- Episiotomy scar
- Extremities
Hormonal Influence
+ Estrogen
- Progseteron
Evidences:
Pregnancy causes atrophy of endometriosis
Regression following oophorectomy and irradiation
Rarely before puberty and after menopause
Sites
Usual sites
Lower pelvis
Cul-de-sac
Uterosacral ligaments
Peritoneum over bladder
Back of uterus
Ovaries
Sigmoid / Appendix
Surgical sites
Episiotomy
Cx stump
Abdominal scar after uterine surgery
Gross appearence
Small black dots (Gun Powder Burns)
Scarring and puckering
Yellowish brown fluid in peritoneal cavity
Chocolate cysts of ovary
Macroscopy
Vascular red adhesions on surface of ovary
Inner surface of cyst wall is vascular with dark brown tissue
Microscopy
Endometrial glands & stroma
Granulation tissue
Hemosiderin laden phagocytic cells
Laproscopic findings
Powder Burn-puckered black spots
Red vascular
Bluish/blackish/chocolate cysts
Dense adhesions in pelvis
Yellow brown peritoneal fluid
Early lesions-red flame like raised areas
Clinical Features
Asymptomatic
Menorrhagia/Polymenorrhoea.
Dysmenorrhoea
Dyspareunia
Dysuria
Dyschezia and tenesmus
Infertility tubal blockage/ovulation dysfunction
Acute abdomen (rupture of chocolate cyst)
Chronic Pelvic Pain
Dysuria, Hematuria, Hematochezia, Hemoptysis
Physical Findings
- P/A: Cystic swelling-simulates an ovarian tumor (Chocolate cyst)-fixed, tender
- P/V: Tender fixed R/V uterus, Adnexal mass, POD-Nodular
Endocrinology Abnormalities
- Anovulation
- Abnormal follicular development
- Luteal insufficiency
- Premenstrual spotting
- Lutenized unruptured follicle
D/D
PID
Ovarian tumours(benign+malignancy)
Rectal carcinoma
Acute abdomen
Investigations
USG
is not much of help because small lesion can not be detected. Useful in case of chocolate cyst of ovary.
Laparoscopy
lesions can be seen and tissue biopsy as well as treatment can be done.
Diagnosis is only by HPE examination.
Ca 125
Endometriosis vs. PID
Endometriosis
- Pelvic pain
- Congestive dysmen.
- Menorrhagia
- Sterility
- Response to hormones
PID
- Pelvic pain
- Congestive dysmen.
- Menorrhagia
- Sterility
- Response to antibiotics
Basis of treatment
Depends on
symptoms
Age
Desire to conceive
Need for conserving reproductive function
Extent of Disease
Response to Medical treatment
Objectives of Rx
To give comfort from disease
Facilitate child bearing
Treatment
For pain
For mass
For infertility
1.Expectant
2.Medical
3.Surgical
-conservative
-Radical
4. Combined
Management plan
Medical Treatment
Drug
- Oral contraceptive pills
- Progestogens
- Androgens
- GnRH analogues
Combined OCPs
1. Continuous 2tabs per day may need to increase for 6-9 months
Warnings; High incidence of side effects, risk of thromboembolism
Oral progestogens
Mode of action: Antiestrogenic effect. Continuous administration– endometrial atrophy
Duration: 6 to 9 months daily
Medroxyprogesterone acetetate
- Dose– Given Intramuscular
- Long acting depot preparation
- 100mgs im every two weeks—3 months
- 200mgs monthly for 3 to 6 months
- ORAL- 30mgs daily
Results of Progestational Agents
50 to 70% symptomatic relief
SIDE EFFECTS: Weight gain
Irregular bleeding. Reduced libido. Mental depression. Breast tenderness.
Danazol
Synthetic derivative of Ethinyl testosterone
Action: Inhibits Pituitary gonadotrophins
Also, mildly anabolic, antioestrogenic and anti progestational
Effective though expensive
Dose: 200 to 800mgs daily for 6 to 8 months-start on first day of menses
If > 8 months symptoms of menopause
Lesions regress but side effects
Weight gain, hirsuitism, sweating, muscle cramps, depression, atrophy of breasts and vaginal epithelium, liver and renal damage
Antinflammatory drugs
Mefenamic acid 500mgs thrice a day
Helps dysmenorrhoea in 70 to 80% patients
GnRH
Gonadotrophin releasing hormone-
given continuously to supress pituitary
gonadotrophins --- causes atrophy of the endometriotic tissue
Cost is a limiting factor
Ablation of endometriotic implants <3cms Laparoscopy
Methods:
Diathermy
CO2 vaporization
laser
SURGERY
For advanced cases/larger lesions
Procedures
- Dissection/excision of chocolate cyst
- Salphingo-ophorectomy
- Abdominal hysterectomy
+
Pre/post operative medical Rx
ADENOMYOSIS
Islands of endometrium (endometrial glands surrounded by stroma) found in the myometrium
Uterus up to14 wks size
Diffuse, non-capsulated involvement of myometrium with tiny dark haemorrhagic areas interspersed in between.
Symptoms
- Parous around 40 yrs
- Menorrhagia, increasing dysmenorrhoea
- Pelvic discomfort
- Backache
- Dyspareunia
Diagnosis
- Symmetric enlargement of uterus (seldom>14 wk)
- Menorrhagia
- Dysmenorrhoea
Surgery is the treatment of choice
Final diagnosis is on the histopathology
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