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ENDOMETRIOSIS - Dr. Roopa Sree

Introduction

The endometrium is the innermost lining of the uterus and is comprised of columnar epithelium and specialized stroma.

The superficial layer of endometrium contains hormonally sensitive spiral arterioles distinct to this layer.

Spasms of these arterioles result in shedding of this layer after each menstrual cycle.

The deeper basal layer has a different arterial supply

and is preserved with each cycle.

DEFINITION

Presence of this endometrial tissue at a place other than it’s normal location is called as endometriosis.

It is a progressive, debilitating disease affecting general, physical, social and mental well-being of a female.

It affects approximately 7-10% of women in reproductive age, 30% of these being infertile or may present with pain.

Most frequent sites at which endometriosis is prone to occur are pelvic viscera and the peritoneum.

Prevalence

Age

Prevalence

Sites of Endometriosis

SiteS of endometrioSiS ….

etiopathogenesis

First described by Daniel Shroen in 1690 but still we are not very sure of it’s definitive cause.

The last three decades have witnessed a significant volume of research related to endometriosis.

Incidence is increasing owing to changing life style.

Increased awareness and better diagnostic modalities.

Endometriosis is considered to be an enigmatic disease owing to Lack of specific symptoms Poorly understood pathogenesis Limited effective therapeutic options

Is it inherited ?

No Mendelian pattern of inheritance,

Multi factorial inheritance is suggested.

Risk of endometriosis is seven times if first degree relative is affected.

75% incidence in monozygotic twins.

No mutations have been identified so far.

Aneuploidy – chromosome 11, 16, 17

Losses of 1p, 22q, 5p, 6q, 16,& 18 have been demonstrated in endometriotic cells.

Why does endometriosis occur ?

Transplantation theory (sampson)

Coelomic metaplasia theory (Mayer and Ivanoff)

Induction theory (merril)

Genetic factors

Immunologic factors

Implantation theory

Sampson's pioneering work in 1992 attributed endometriosis to reflux of menstrual endometrium through the fallopian tubes.

Occurrence of scar endometriosis following classicaI caesarean section, hysterotomy, myomectomy and episiotomy further supports this view.

Coelomic metaplasia

Meyer and Ivanoff (1991) propounded that endometriosis arises as a result of metaplastic changes in embryonic cell rests of embryonic mesothelium .

Ovarian endometriotic lesions may arise directly from ovarian surface epithelium through a metaplastic differentiation process induced by activation of an oncogenic K-ras allele.

Induction theory

This is an extension of coelomic metaplasia theory.

It proposes that an endogenous biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissues.

Metastatic theory

Suggested by Halban et al (1924) that

embolization of menstrual fragments

through vascular or lymphatic

channels, explain its occurrence at

less accessible sites Iike the umbilicus,

pelvic lymph nodes, ureter,

rectovaginal septum, bowel walI, and

remote sites Iike the lung, pleura,

endocardium and the extremities.

Hormonal influence

The initial genesis of endometriosis, its further development depends on the presence of hormones, mainly oestrogen.

Pregnancy causes atrophy of endometriosis through high progesterone level.

Regression also follows oophorectomy and irradiation.

Endometriosis is rarely seen before puberty and it regresses after menopause.

Hormones with anti-oestrogenic activity also suppress endometriosis and are used therapeuticaIly.

Immunological factor

The peritoneal fluid in endometriosis shows the presence of macrophages and natural killer (NK) cells.

lmpaired T cell and NK cell activity and altered immunology.

Other factors: Genetic - familial tendency reported in 15% cases, multifactorial, vaginal or cervical atresia which encourage retrograde spill.

Chocolate cyst

Cyst enlarges with cyclic bleeding.

The serum gets absorbed in between periods, content inside the cyst becomes chocolate coloured, hence named chocolate cyst.

Commonly located in ovary.

Also known as endometrial cyst, Endometrioma.

ChoColate CySt….

Ectopic deposition of endometrium

Only proliferative changes due to deficiency of progesterone receptors

Cyclic growth and shedding

Shedded blood may remain encysted, cyst becomes tense and ruptures.

This ruptured blood becomes irritant causes dense tissue reaction leading to fibrosis within pelvic peritoneum

Endometriotic lesions

Variable appearance

Peritoneum

Typical / Superficial

Early red lesions

powder burn or gun shot lesions

Black, dark brown or bluish

Deeply infiltrating endometriosis>4mm

Atypical or subtle lesion

Serous/clear vesicles

Yellowish discoloration

CLINICAL FEATURES

INVESTIGATIONS

USG

LAPAROSCOPY

CA-125

TREATMENT - MEDICAL

1. Combined oral contraceptives

2. Oral progestogens

3. Danazol

4. Aromatase inhibitors

5. Gonadotropin releasing hormone

6. RU - 486

TREATMENT - SURGICAL

1. Destruction of endometriotic implants <3cms by laser

2. Larger lesions & chocolate cyst can be excised

3. Laparoscopic breaking of adhesions in pelvis

4. Incision of chocolate cyst and removal of lining

5. Salpingo-oophorectomy

6. TAH + BSO

7. Excision of scar endometriosis