Endometriosis A Gynecology topic for MBBS

1. Endometriosis
Labeeb Pc
102

2. Topics to be dicussed…
 Introduction
 Pathogenesis
 Risk factors
 Classification
 Symptoms
 Physical examination
 Differential diagnosis
 Investigations
 Staging

3. Introduction
Presence of endometrial glands & stroma
outside the uterus
Benign
Incidence – 10%

4. Pathogenesis
1. Implantation Theory ( Sampson’s)
2. Coelomic metaplasia Theory ( Meyer )
3. Lymphatic & Vascular Metastatic Theory ( Halban )
4. Hormonal - estrogen
5. Genetic
6. Immunological

5. Implantation Theory
(Sampson’s)
 Retrograde menstruation
 Common in obstructive Mullerian anomalies,
cryptomenorrohea.
 Women with short & heavy menstrual cycles
 Scar endometriosis
 Dependant portion of pelvis

6.  Cytokines - Adhesion to peritoneal surface
 MMP - Invasion
 VEGF-A - Angiogenesis
 Growth factors - Growth
 Estrogen - Proliferative change
 Prostaglandin - inflammation, pain

7. Sites
Common – ovaries, pouch of Douglas,
uterosacral ligaments, Broad ligaments, fallopian
tubes, uterovesical fold, round ligament, appendix ,
vagina
Rectovaginal septum, sigmoid colon, cecum,
umbilicus, abdominal scars, tubal stumps

9. Risk Factors
1. Menstrual cycle
 Early menarche
 Heavy menstrual bleeding
 Short menstrual cycles
2. Delayed childbearing
3. Parity
 Low parity, nulliparous
4. High social class
5. First degree relatives
6. Low BMI
7. Obstructive Mullerian anomalies
8. Environmental

10. Classification
1. Superficial endometriosis
2. Ovarian endometriosis
3. Deep infiltrating endometriosis

11. Superficial Endometriosis
( Peritoneal)
 Dependent portion of pelvis.
 Most common – surface of ovaries.
 Pelvic peritoneum, pouch of Douglas, uterosacral ligaments,
Broad ligaments.
 Appearance –
 Early - Papular, vesicular
 Hemorrhagic - red, flame shaped
 Powder burn - puckered, blue- black - inactive old lesions
 Fibrotic - white
 Peritoneal cavity – yellowish brown fluid

12.  Cannot be palpated on clinical examination
 Difficult to visualise on imaging and diagnosis by laparoscopy

13. Ovarian Endometriosis
( Ovarian Endometrioma)
 Inversion & invagination of ovarian cortex , with superficial
endometriotic deposits.
 Adhesion of ovary to post. Peritoneum
 Chocolate Cysts.
 Cyst wall white or yellow.
 <12cm
 Histology- pseudoxanthoma cells - macrophages , are brown.

16. Deep Infiltrating Endometriosis
( Posterior Pelvic Endometriosis )
 Lesion extends >5mm beneath peritoneum.
 Usually in rectovaginal space,
also uterosacral ligaments, cervix , bowel or ureters.
 Can be felt on pelvic & per rectum examination – tender
induration & nodularity
 Can be visualised on imaging.

17. Extrapelvic Endometriosis
 Urinary tract
 GI tract
 Surgical scars
 Pulmonary

18. Symptoms
 Classic symptoms – Dysmenorrhoea, Dyspareunia, deep
seated pelvic pain.
 Menstrual – menorrhagia, Premenstrual spotting
 Infertility
 Cyclical bowel & bladder symptoms
 Scar endometriosis – cyclical pain
 Cyclical haemoptysis & haemothorax

19. Causes of infertility
 Ovulatory dysfunction
 Anovulation
 Luteal phase defect
 Luteinised unruptured follicle syndrome
 Immunological alteration
 Mechanical factors
 Dyspareunia
 Endometrial dysfunction
 Sperm inactivation

20. Physical Examination
1. Abdominal examination
 ovarian mass – tender, fixed, in iliac fossa
2. Per speculum examination
 Vaginal lesions – bluish puckered spots
3. Pelvic examination
 Fixed retroverted uterus
 Adnexal mass
 Tender uterosacral ligaments
4. Per rectal examination

21. Differential Diagnosis
1. Chronic PID
2. Uterine myomas
3. Ovarian malignant tumour
4. Rectal Ca
5. a/c abdominal catastrophe
6. c/c pelvic congestion syndrome

22. Investigations
1. USG
 Useful in ovarian endometrioma.
 Ovarian mass- Cysic mass, low level internal echoes
2. MRI
 Useful in ovarian endometrioma
 Endometrioma > 3cm
 Rectovaginal nodules
3. Doppler ultrasound
4. CA 125 > 35u/ml
 Abdominal TB, PID, ovarian tumour, c/c liver disease, menstruation,
5. Barium studies
6. Intravenous urography

23. Laparoscopy
 Gold standard for diagnosis.
 Visualisation of lesions
 Staging of disease
 Biopsy for histology
 Evaluate extend of adhesions
 Therapeutic

26. Classification & Staging
 American Society For Reproductive Medicine ( ASRM )
 Based on - appearance, size, depth, presence & extent of
adnexal adhesions and degree of obliteration of pouch of
Douglas
 To describe extent of disease, plan management.
 Drawback – doesn’t take into account pain or inferitlity

28.  STAGE 1(MINIMAL) -SCORE 1-5
 STAGE 2 (MILD) -SCORE 6-15
 STAGE 3(MODERATE) -SCORE 16-40
 STAGE 4(SEVERE) - SCORE >40