ENDOMETRIOSIENDOMETRIOSISS

DEPT OF OBS & GYNAECDEPT OF OBS & GYNAEC

AMCAMC

ENDOMETRIOSISENDOMETRIOSIS

DEFINITION: presence of DEFINITION: presence of endometrial tissue (glands & endometrial tissue (glands & stroma) outside the uterine cavity.stroma) outside the uterine cavity.

Incidence is about 10%.Incidence is about 10%. Most common in women of Most common in women of

reproductive age group.reproductive age group. It is an oestrogen dependent It is an oestrogen dependent

disease.disease.

ETIOLOGYETIOLOGY

Various theories proposed to explain Various theories proposed to explain the histogenesis of endometriosis:the histogenesis of endometriosis:

1)IMPLANTATION THEORY1)IMPLANTATION THEORY 2)COELOMIC METAPLASIA THEORY2)COELOMIC METAPLASIA THEORY 3)INDUCTION THEORY3)INDUCTION THEORY 4)METASTATIC THEORY4)METASTATIC THEORY 5)HORMONAL INFLUENCE THEORY5)HORMONAL INFLUENCE THEORY 6)IMMUNOLOGICAL THEORY6)IMMUNOLOGICAL THEORY

ETIOLOGY contd.,ETIOLOGY contd.,

Implantation theoryImplantation theory: this theory explains : this theory explains that endometriosis is caused by that endometriosis is caused by implantation of endometrial cells by trans implantation of endometrial cells by trans tubal retrograde menstruation.tubal retrograde menstruation.

eg.1) Endometriosis in dependent eg.1) Endometriosis in dependent portions of pelvis – ovaries, uterosacral portions of pelvis – ovaries, uterosacral lig., cul-de-sac etc.,lig., cul-de-sac etc.,

2) Scar endometriosis following 2) Scar endometriosis following classical caesarian section, hysterotomy classical caesarian section, hysterotomy & episiotomy.& episiotomy.

ETIOLOGY contd., ETIOLOGY contd.,

Coelomic Metaplasia theoryCoelomic Metaplasia theory: : endometriosis arises as a result of endometriosis arises as a result of metaplastic changes in embryonic cell metaplastic changes in embryonic cell rests of embryonic mesothelium which rests of embryonic mesothelium which respond to hormonal stimulation.respond to hormonal stimulation.

Induction theory:Induction theory: it proposes that an it proposes that an endogenous biochemical factor can endogenous biochemical factor can induce undifferentiated peritoneal cells induce undifferentiated peritoneal cells to develop into endometrial tissue.to develop into endometrial tissue.

ETIOLOGY contd.,ETIOLOGY contd., Metastatic theoryMetastatic theory: this thoery explains : this thoery explains

extra pelvic endometriosis which result extra pelvic endometriosis which result from vascular or lymphatic dissemination from vascular or lymphatic dissemination of endometrial cells to gynaecological of endometrial cells to gynaecological ( vulva, vagina, cervix) and non ( vulva, vagina, cervix) and non gynaecological sites like bowel, pelvic gynaecological sites like bowel, pelvic lymph nodes, ureter, lung, pleura etc.lymph nodes, ureter, lung, pleura etc.

Hormonal Influence theoryHormonal Influence theory: after : after implantation development of implantation development of endometriotic implants depend on endometriotic implants depend on presence of hormones mainly oestrogen.presence of hormones mainly oestrogen.

ETIOLOGY contd.,ETIOLOGY contd.,

Immunological theoryImmunological theory: : endometriosis can be caused by endometriosis can be caused by decreased clearance of peritoneal decreased clearance of peritoneal fluid endometrial cells resulting from fluid endometrial cells resulting from reduced Natural Killer cell activity reduced Natural Killer cell activity or decreased macrophage activity.or decreased macrophage activity.

SITES OF SITES OF ENDOMETRIOSISENDOMETRIOSIS

Most common site is ovary.Most common site is ovary. Other sites – cul-de-sac including Other sites – cul-de-sac including

uterosacral lig., back of uterus, uterosacral lig., back of uterus, posterior broad lig, peritoneum posterior broad lig, peritoneum overlying bladder, intestinal coils etc.,overlying bladder, intestinal coils etc.,

Scar endometriosis occur in umbilicus Scar endometriosis occur in umbilicus following laparotomy, tubal stumps following laparotomy, tubal stumps following tubectomy, amputated following tubectomy, amputated stumps of cervix, episiotomy scars etc,stumps of cervix, episiotomy scars etc,

SITES OF SITES OF ENDOMETRIOSISENDOMETRIOSIS

PATHOLOGYPATHOLOGY

An endometriotic lesion appears as An endometriotic lesion appears as dark red, bluish or black cystic area dark red, bluish or black cystic area adherent to site where it is lodged.adherent to site where it is lodged.

Scarring around the lesion gives Scarring around the lesion gives puckered appearance.puckered appearance.

Powder burnt areas represent Powder burnt areas represent inactive lesions.inactive lesions.

PERITONEAL PERITONEAL ENDOMETRIOSISENDOMETRIOSIS

BLUE –BLACK BLUE –BLACK APPEARANCE OF LESIONS APPEARANCE OF LESIONS

HISTOLOGYHISTOLOGY

Histological confirmation is essential Histological confirmation is essential in the diagnosis of endometriosis.in the diagnosis of endometriosis.

Microscopically, endometrial Microscopically, endometrial implants consist of endometrial implants consist of endometrial glands & stroma with or without glands & stroma with or without hemosiderin laden macrophages.hemosiderin laden macrophages.

Endometriod stroma is more Endometriod stroma is more characteristic of endometriosis than characteristic of endometriosis than endometrial glands.endometrial glands.

HISTOLOGY OF HISTOLOGY OF ENDOMETRIOTIC LESIONENDOMETRIOTIC LESION

CHOCOLATE CYST OF CHOCOLATE CYST OF OVARYOVARY

Also called as endomeriotic cyst of ovary.Also called as endomeriotic cyst of ovary.Exclusive ovarian disease found in only 1% of Exclusive ovarian disease found in only 1% of

patients.patients.Ovarian endometriosis appears to be a marker of Ovarian endometriosis appears to be a marker of

more extensive pelvic & intestinal disease.more extensive pelvic & intestinal disease.FORMATION OF CHOCOLATE CYST:FORMATION OF CHOCOLATE CYST:Islets of endometriosis show cyclical changes Islets of endometriosis show cyclical changes

during menstruation menstrual blood & during menstruation menstrual blood & debris collectdebris collect collection with each collection with each episode absorption of fluid causes blood to episode absorption of fluid causes blood to become dark coloured to produce chocolate become dark coloured to produce chocolate cyst. cyst.

CHOCOLATE CYST cont,CHOCOLATE CYST cont, Features of choclate cyst:Features of choclate cyst: 1.cyst diameter <12 cm1.cyst diameter <12 cm 2.adhesion to pelvic side wall or broad2.adhesion to pelvic side wall or broad liglig 3.endometriosis on surface of ovary3.endometriosis on surface of ovary 4.contains tarry,thick,chocolate 4.contains tarry,thick,chocolate coloured fluidcoloured fluid It consists of thick tunica albuginea & It consists of thick tunica albuginea &

vascular red adhesions on undersurface of vascular red adhesions on undersurface of ovary.ovary.

CHOCOLATE CYSTCHOCOLATE CYST

CHOCOLATE CYST OF CHOCOLATE CYST OF OVARYOVARY

CLASSIFICATIONCLASSIFICATION

Revised American Fertility SocietyRevised American Fertility Society ClassificationClassification

Classification based on size & location Classification based on size & location of the endometriotic lesion.of the endometriotic lesion.

Classified as minimal, mild, moderate Classified as minimal, mild, moderate & severe.& severe.

Classification correlated with fertility Classification correlated with fertility outcome rather than symptoms.outcome rather than symptoms.

CLASSIFICATIONCLASSIFICATION

CLINICAL FEATURESCLINICAL FEATURES SYMPTOMS:SYMPTOMS: classical symptoms include classical symptoms include

dysmenorrhoea, dyspareunia & infertility.dysmenorrhoea, dyspareunia & infertility. Dysmenorrhoea:Dysmenorrhoea: usually congestive type. usually congestive type. pain related to location not extent of pain related to location not extent of

lesion.lesion. DyspareuniaDyspareunia: involvement of cul-de-sac & : involvement of cul-de-sac &

uterosacral lig., produce adhesions & uterosacral lig., produce adhesions & fixation of uterus. Movements of cervix fixation of uterus. Movements of cervix elicit tenderness.elicit tenderness.

CLINICAL FEATURESCLINICAL FEATURES InfertilityInfertility: involvement of ovaries produce : involvement of ovaries produce

adhesions blocking tubo-ovarian motility & adhesions blocking tubo-ovarian motility & ovum pick up leading to infertility.ovum pick up leading to infertility.

Chronic pelvic painChronic pelvic pain: brownish yellow : brownish yellow peritoneal fluid containing PGE2 is peritoneal fluid containing PGE2 is responsible for pain.responsible for pain.

Endocrinological abnormalitiesEndocrinological abnormalities: anovulation, : anovulation, luteal insufficiency, lutenisation of unruptured luteal insufficiency, lutenisation of unruptured follicle, hyperprolactinemia etc,follicle, hyperprolactinemia etc,

OthersOthers:: adhesions around ureter produce adhesions around ureter produce hydronephrosis, painful defaecation & hydronephrosis, painful defaecation & melaena due to invol., of sigmoid colon. melaena due to invol., of sigmoid colon.

ENDOMETRIOSIS LESIONS ENDOMETRIOSIS LESIONS & ADHESIONS& ADHESIONS

CLINICAL FEATURESCLINICAL FEATURES

SIGNSSIGNS::

abdominal examinationabdominal examination: may reveal tender & : may reveal tender & fixed cystic mass in case of chocolate cyst.fixed cystic mass in case of chocolate cyst.

Speculum examinationSpeculum examination: may reveal bluish or : may reveal bluish or blackish puckered spots in posterior fornix.blackish puckered spots in posterior fornix.

P/VP/V: may reveal fixed tender retroverted : may reveal fixed tender retroverted uterus, cobble stone feel of uterosacral lig, uterus, cobble stone feel of uterosacral lig, thickened nodules in pouch of douglas etc,thickened nodules in pouch of douglas etc,

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

Pelvic inflammatory diseaesPelvic inflammatory diseaes Uterine myomasUterine myomas Malignant ovarian disease with Malignant ovarian disease with

metastasis in pouch of douglasmetastasis in pouch of douglas D.D of acute abdomen in case of D.D of acute abdomen in case of

ruptured chocolate cystruptured chocolate cyst Chronic pelvic congestion syndromeChronic pelvic congestion syndrome Rectal carcinoma when involves Rectal carcinoma when involves

rectovaginal septumrectovaginal septum

INVESTIGATIONSINVESTIGATIONS

Ultrasound: TVS may reveal an echo free Ultrasound: TVS may reveal an echo free cyst whose wall is thick & irregular.cyst whose wall is thick & irregular.

Laparoscopy: Laparoscopy: laparoscopy is gold laparoscopy is gold standard in the diagnosis of standard in the diagnosis of endometriosisendometriosis..

Histological confirmationHistological confirmation CA125:it is a glycoprotein & cell surface CA125:it is a glycoprotein & cell surface

antigen. Raised >35U/ml proportional to antigen. Raised >35U/ml proportional to extent of disease. Raised level indicate extent of disease. Raised level indicate recurrence or persistence of disease.recurrence or persistence of disease.

TREATMENTTREATMENT If asymptomatic observe for 6-8 months.If asymptomatic observe for 6-8 months. Medical treatmentMedical treatment : : Indications: a) mild pelvic endometriosisIndications: a) mild pelvic endometriosis b)to treat residual& recurrent b)to treat residual& recurrent disease following surgerydisease following surgery OC PILLS: the objective of treatment is induction OC PILLS: the objective of treatment is induction

of amenorrhoea pseudo pregnancy & of amenorrhoea pseudo pregnancy & decidualisation of endometrial tissue which decidualisation of endometrial tissue which relieves pain & dysmenorrhoea.relieves pain & dysmenorrhoea.

Dose :low dose OCP containing 30-35mcg of Dose :low dose OCP containing 30-35mcg of oestrogen for 6-12 months.oestrogen for 6-12 months.

PROGESTINS: considered as first choice for PROGESTINS: considered as first choice for treatment of endometriosis with lower incidence treatment of endometriosis with lower incidence of side effects. of side effects.

TREATMENTTREATMENT DANAZOL: inhibits pituitary gonadotropins. DANAZOL: inhibits pituitary gonadotropins.

It has anti-oestrogenic ,anti progestational It has anti-oestrogenic ,anti progestational & androgenic.& androgenic.

Dose: 200-800mg for 3-6 months.Dose: 200-800mg for 3-6 months. GnRH ANALOGUES: cause atrophy of GnRH ANALOGUES: cause atrophy of

endometrial tissueendometrial tissue AROMATASE INHIBITORS- letrozoleAROMATASE INHIBITORS- letrozole MINIMALLY INVASIVE SURGERY:MINIMALLY INVASIVE SURGERY: Goal of surgery is to excise all visible Goal of surgery is to excise all visible

endometriotic lesion & associated adhesions endometriotic lesion & associated adhesions & restore normal anatomy.& restore normal anatomy.

MINIMALLY INVASIVE MINIMALLY INVASIVE SURGERYSURGERY

Ovarian endometrioma < 3cm in Ovarian endometrioma < 3cm in diameter removed by vapourisation diameter removed by vapourisation by CO2 OR Nd:YAG laser.by CO2 OR Nd:YAG laser.

Ovarian cystectomy done for ovarian Ovarian cystectomy done for ovarian endometriotic cyst > 3 cm in endometriotic cyst > 3 cm in diameter.diameter.

Laparoscopic adhesiolysis: restore Laparoscopic adhesiolysis: restore patency of tubes.patency of tubes.

LUNA(laparoscopic uterosacral nerve LUNA(laparoscopic uterosacral nerve ablation): relieves pain.ablation): relieves pain.

LAPAROSCOPIC LAPAROSCOPIC ADHESIOLYSISADHESIOLYSIS

LAPAROSCOPIC EXCISION LAPAROSCOPIC EXCISION OF ENDOMETRIOTIC CYSTOF ENDOMETRIOTIC CYST

TREATMENTTREATMENT

LAPAROTOMYLAPAROTOMY: presevered for advanced : presevered for advanced stage disease.stage disease.

Salpingo-oophorectomySalpingo-oophorectomy Abd hysterectomy & bil salpingo-Abd hysterectomy & bil salpingo-

oophorectomy.oophorectomy. COMBINED TREATMENTCOMBINED TREATMENT: pre operative : pre operative

medical treatment reduce vascularisation medical treatment reduce vascularisation & size of nodules.& size of nodules.

post operative treatment decerase the post operative treatment decerase the incidence of recurrence.incidence of recurrence.

PROPHYLAXISPROPHYLAXIS

Low dose OCP reduce endometrial Low dose OCP reduce endometrial growth & protect against growth & protect against endometriosis.endometriosis.

Tubal patency tests should be avoided Tubal patency tests should be avoided in immediate pre menstrual phase.in immediate pre menstrual phase.

Operations on the genital tract should Operations on the genital tract should be done in post menstrual phase.be done in post menstrual phase.

Classical c/s & hysterotomy may Classical c/s & hysterotomy may cause scar endometriosis & hence cause scar endometriosis & hence should be avoided. should be avoided.