Dr. Suman Gupta Prof. and Head, - PowerPoint Presentation

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Dr. Suman Gupta

Prof. and Head,

Obs

&

Gynae

Department.

ENDOMETRIOSIS

Definition

The presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis. It is not a neoplastic condition, these ectopic endometrial tissues may be found in the myometrium when it is called endometriosis interna or adenomyosis.

Prevalence

During the last couple of decades, the pervalence of endometriosis has been increasing both in terms of real and apparent. The real one is due to delayed marriage, postponement of first conception and adoption of small family norm. The apparent one is due to increased use of diagnostic laparoscopy as well as hightened awareness of the disease the prevalence is about 10 per cent. However, prevalence is high amongest the infertile women (30-40%) as based on diagostic laparoscopy and laparotomy.

Abdominal Extra-abdominal Remote

Abdominal

It can occur at any site but is usually confined to the abdominal

structures

below the level of unbilicus. Common structures involved in order of frequency are ovary, pouch of douglas, uterosacral ligament, broad ligament, rectovaginal septum, rectum and pelvic lymph nodes. Rare sites are gut appendix, ureter and urinary bladder.

Extra-abdominalThe common sites are abdominal scar of hysterotomy, caesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix.

Coelomic metaplasia (Meyer and Ivanoff)

Chronic irritation of the pelvic peritoneum by the menstrual blood may cause coelomic metaplasia which results in endometriosis.

Pathology

General considerations

The endometrium (glands and stroma) in the ectopic sites has got the potentiality to undergo change under the action of ovarian hormones.

While proliferative changes are constantly evidenced, the secretory changes are conspicuously absent in many;

Cyclic growth and shedding continue till menopause.

As the blood is irritant, there is dense tissue reaction surrounding the lesion with fibrosis.

Fallopian remain patent.

Pelvic endometriosis

Typically,there are small black dots, the so called ‘powder burns’ seen

on tyhe uterosacral ligaments and pouch of douglas. Fibrosis and

scarring in the peritoneum surrounding the implants is also a typical

finding. Other subtle appearances are : red flame shaped areas, red

polypoid areas, yellow brown patches,powders burn the ovaries are

frequently involved usually bilaterally. The endometriomas

(chocolate cysts ) are of varying sizes and are visible as bluish

Colouratious. The ovaries get adherent to the pelvic structures including rectum and sigmoid colon.

CLINICAL FEATURES OF PELVIC ENDOMETRIOSIS

Patient profile

Symptoms

About 25 per cent of patients with endometriosis have no symptom, beaing accidentally discovered either during laparoscopy or laparotomy.

Symptoms are not related with extent of lesion.

Depth of penetration is more related to symptoms rather than the spread. Lesions penetrating more than 5 mm are responsible for pain, dysmenorrhoea and dyspareunia.

Non-pigmented endometriotic lesions compared to classic pigmented “powder burns” lesions produce more prostaglandin F (PGF) and hence are more painful.

The symptoms are mostly related to the site of lesion and its ability to respond to hormones. Midline lesions are more symptom

Dysmenorrhoea(50%)

There is progressively increasing secondary dysmenorrhoea. The pain starts a few days prior to menstruation; gets worsened during menstruation and takes time, even after cessation of period, to get relief of pain, the site of pain is usually deep seated and on the back or rectum.

Increased secration of PGF 2a, thromboxane B2 from endometriotic tissue is the cause of pain.

Abnormal menstruation(60%)

Menorrhagia is the predominant abnormality. If the ovaries are also involved, polymenorrhoea

Infertility(40-60%)

Whether endometriosis causes infertility or infertilityproduces endometriosis is not clear. Endometriosis is found in 20-40 per cent of infertile women.

Dyspareunia

The dyspareunia is usually deep. It may be due to stretching of the structures of the pouch of douglas or direct contact tenderness. As such, it

Is mostly found in endometriosis of the rectovaginal septum or pouch of douglas and with fixed retroverted uterus.

Abdominal Pain

There may be variable degrees of abdominal pain around the periods. Somethimes, the pain may be acute due to rupture of chocolate cyst.

Chronic pelvic pain

Other Symptoms

Bladder – frequency, dysuria or even haematuriaSigmoid colon and rectum – painful defecation (dyschezia), diarrhoea, rectal bleeding or even melena.

Abdominal examination

A mass may be felt in the lower abdomen arising from the pelvis – enlarged

chocolate cyst or tubo-ovarian mass due to endometrioyic adhesions. The

mass is tender with restricted mobility.

Pelvic examination

Bimanual examination may not reveal any pathology. The expected positive findings are – pelvic tenderness, nodules in the pouch of douglas, nodular feel of the uterosacral ligaments, fixed retroverted uterus or unilateral or bilateral adnexal mass of varying sizes.

DIAGNOSIS

Serum Marker CA 125

Imaging

Ultrasonography

Computed tomography (CT)

Confirmation is by double puncture laparoscopy (gold standard) or by laparotomy.

Biopsy confirmation

DIFFERENTIAL DIAGNOSIS

Chronic pelvic infection

Ovarian endometrioma (chocolate cyst)

Benign ovarian tumour

Malignant ovarian

COMPLICATIONS OF ENDOMETRIOSIS

The following complications may occur:

Endocrinopathy – This may be mostly responsible for infertility.

Rupture of chocolate cyst.

Infection of chocolate cyst.

Obstructive features:

- Intestinal obstrucation hydroureter

- hydronephrosis renal infection

5. Malignancy is rare, the commonest one being abenoacanthoma

Levonorgestrel-releasing-IUCD when used, is found to reduce dysmenorrhoea, pelvic pain, dyspareunia and menorrhagia singnificantly useful for rectovaginal endometriosis.

SURGICAL MANAGEMENT OF ENDOMETRIOSIS

INDICATIONS

Endometriosis with severe symptoms unresponsive to hormone therapy.

Severe and deeply infiltrating endometriosis to correct the distortion of pelvic anatomy.

Endometriomas of more than 1 cm.

CONSERVATIVE SURGERY

Conservatine surgery is planned to destroy the endometriotic lesions

in an attempt to improve the symptoms (Pain, subfertility) and at

the same time to preserve the reproductive function.

Laparoscopy is commonly done to destroy endometriotic lesions by

excision or ablation by electrodiatherapy.

Laparoscopic uterosacral

nerve ablation (LUNA)