Endometriosis

DEFINITION

 Presence of endometrial tissue (both glands & stroma) outside the uterus.
 Tissue

AETIOLOGY: theories

Sampson’s theory of menstrual regurgitation and implantation (Metastatic theory)
Retrograde menstruation
↓
Endometrial

Coelomic metaplasia theory:
Original Coelomic membrane transforms into endometrial tissue.
Explains endometriosis in

4. Immunological factors: reduced clearance of endometrial cells due to decreased natural

SITES

TYPES OF ENDOMETRIOSIS

PELVIC ENDOMETRIOSIS

EXTRA PELVIC ENDOMETRIOSIS

Peritoneal

Gastrointestinal tract

Ovarian

Urinary tract

Deep infiltrating

Scar endometriosis

Vaginal endometriosis

Thoracic

CLINICAL PRESENTATION

PAIN:
Classical triad: dysmenorrhea, dyspareunia & deep seated pelvic pain.
Commence before

ABNORMAL BLEEDING:
May include premenstrual spotting, polymenorrhoea & menometrorrhagia.
INFERTILITY:
Present in majority of

OTHER SYMPTOMS
Extrapelvic endometriosis: cyclical rectal bleeding or hematuria.
Scar endometriosis: cyclical pain

SIGNS & SYMPTOMS

SIGNS
Tenderness in cul-de-sac
Nodularity in cul-de-sac
Fixed retroverted uterus
Adnexal tenderness
Adnexal masses

SYMPTOMS
Dysmenorrhoea
Dyspareunia
Deep

INVESTIGATIONS

TRANSVAGINAL ULTRASOUND SCAN

Retroverted uterus with obliteration of cul-de-sac & B\L complex

CA-125

 Increased in moderate to severe endometriosis
 Also increased in non-mucinous epithelial ovarian

LAPAROSCOPY

Gold Standard
During laparoscopy, entire pelvis should be examined systematically in clockwise

1. PERITONEAL LESION

CLASSIC LESIONS:
Powder burn or gunshot lesion: black to dark

2. OVARIAN ENDOMETRIOSIS

ENDOMETRIOMA OE CHOCOLATE CYST:
Cyst contains thick tarry fluid- chocolate

3. DEEP INFILTRATING ENDOMETRIOSIS

Lesions are usually in rectovaginal space.
May involve uterosacral

4. EXTRAPELVIC ENDOMETRIOSIS

GASTROINTESTINAL TRACT:
Frequently involved: sigmoid, rectum, iliocaecum & appendix.
Symptoms: abdominal

Extrapelvic endometriosis cont.

SCAR ENDOMETRIOSIS:

Seen at umbilicus, port sites following laparoscopy, abdominal

INVESTIGATIONS

CT & MRI: Identical picture as in USG
COLOUR DOPPLER FLOW: Increased

HISTOLOGY

 Histologic confirmation is essential.
 On microscopy, typical endometrial implant with endometrial glands

CLASSIFICATION OF ENDOMETRIOSIS

Stage I: MINIMAL: Score 1-5
Small spots of endometriosis seen

Stage IV: SEVERE: Score >40
Endometriomas exceed 2cm.
Dense Peritubal & periovarian adhesions

DIFFEERENTIAL DIAGNOSIS

Chronic PID
Postoperative adhesions
Old ectopic gestation
Pelvic congestion syndrome
Irritable bowel syndrome
Diverticulitis
Ulcerative colitis
Crohn’s

MANAGEMENT

Management of Endometriosis

Asymptomatic minimal endometriosis

Observe 6-8 months, Investigate infertility

Symptomatic cases

Drug treatment

Minimal

DRUG TREATMENT

Combined oral contraceptives:
Administered intermittently or continuously.
High Incidence of side effects

DRUG TREATMENT
Danazol
A synthetic derivative of ethinyl testosterone,
Mildly anabolic , anti-oestrogenic and

Drug treatment

Gonadotropin releasing hormone:
GnRH is administered continuously to down regulate and

DRUG THERAPY

Failure of drug therapy is due to :
Drug cannot penetrate

MINIMAL INVASIVE SURGERY

Aspiration of peritoneal fluid in cul-de-sac.
Destruction of endometriotic implants <3cm

MINIMAL INVASIVE SURGERY

Role of surgery:
 Failed Medical therapy
 Infertility
 Recurrence
 Chocolate

SURGERY

Indications for surgery:
 Advanced stage of disease detected
 Large lesion
 Medical therapy fails or

SURGERY

Laparotomy:
In advanced & larger lesions if medical therapy fails.
Dissection and excision

COMBINED THERAPY

Preoperative GnRH:
monthly for 3 months
reduces size & extend of lesions,
softens

PROPHYLAXIS

Low-dose OCP reduce the menstrual flow & protect against endometriosis. 3