1.
Diagnosis
Of
Endometriosis
Dr. Shashwat Jani.
M.S. ( Gynec)
Diploma In Advance Endoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College,
Sheth V. S. General Hospital, Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2.
Introduction
 Endometriosis initially described by Von
Rokitansky in 1860.
 Endometriosis is a clinical and pathological
entity.
 It is characterized by the presence of tissue
resembling functional endometrial glands and
stroma outside the uterine cavity.
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3.
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4.
It is not a neoplastic condition, but
malignant transformation is possible.
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5.
Incidence
 3 – 10 % of women of reproductive
age
 20-40% in infertile women
 5-20% with chronic pelvic pain
 20-50% asymptomatic, found during
laparoscopy and sterilization.
 50% dysmenorrhea
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6.
Etiology
Estrogen dependent disease
 Sampson’s theory
Ectopic transplantation of endometrial tissue.
 Meyer’s theory
Coelomic metaplasia.
 Halban's theory:
Induction theory
Genetic factors
Immunologic factors
Unknown factor
Autoimmune
Combination of the Above
Environmental factors - dioxin
No Single Theory Explains All Cases of
Endometriosis
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7.
Risk Factors
Family history of endometriosis.
Early age of menarche
Short menstrual cycles (<27 d)
 Long duration of menstrual flow (>7 d)
Heavy bleeding during menses
 Inverse relationship to parity
 Delayed childbearing
 Defects in the uterus or fallopian tubes
 less use of OCs
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8.
Diagnosis
 Clinical Presentations
 Clinical Examinations
 Imaging Modalities
 Histological Diagnosis
 Biochemical Markers
 Surgical Diagnosis
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9.
Clinical
Presentation
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10.
Symptoms
 PELVIC - Dymenorrhoea (50%),
Abnormal menstruation (60%)
Dyspareunia,
Chronic Pelvic Pain,
Premenstrual spotting
 GASTROINTESTINAL- Constipation, Diarrhea,
Hematochezia, Tenesmus
 URINARY COMPLAINTS- Flank pain, Back pain,
Abdominal pain, Urgency,
Frequency,Hematuria
 PULMONARY- Haemoptysis , Pneumothorax
 INFERTILTY
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11.
Dysmenorrhea
 Most common symptom
 Pain starts a few days prior to menstruation,
gets worse during menstruation( secondary
dysmenorrhoea)
 Pain due to Increased secretion of PGF2α,
Thromboxane β2 from endometriotic tissue.
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12.
Abnormal Menstruation
- Menorrhagia is a predominant abnormality.
- Polymennorhoea, premenstrual spotting also
occur.
Dyspareunia
It is usually deep, due to stretching of the structures of the
Pouch of Douglas or direct contact tenderness found in
endometriosis of rectovaginal septum or Pouch of
Douglas and with fixed retroverted uterus.
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13.
Lower Abdominal Pain
Abdominal pain
lower abdominal pain or backache
May be due to inflammation in
peritoneal implants due to cystic bleeding
Irritation or invasion of nerve
Action of inflammatory cytokines
released by the macrophages.
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14.
Infertility
• Mechanical interference---
• Pelvic adhesions
• Chronic salpingitis
• Impaired oocyte pickup
• Altered tubal motility
• Distortion of tubo-ovarian relations
• Alteration in peritoneal fluid
• Increased concentration of prostaglandins
• Increased number of macrophages
• Increased production of cytokines
• Phagocytosis of sperms
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15.
• Abnormal Systemic Immune system
• Increased cell-mediated gametes injury
• Increased prevalence of autoantibodies
• Hormonal or ovulatory dysfuntion
• Defective folliculogenesis
• Luteinized unruptured follicle syndrome
• Hyperprolactinemia
• Luteal phase deficiency
• Implantation failure
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16.
Clinical Examination
General conditions-
Pallor + due to Menorrhagia
P/A - Mass may be felt in lower abdomen arising from
the pelvis
Enlarged chocolate cyst or tuboovarian mass,
due to endometriotic adhesions.
The mass is tender with restricted mobility.
L/E- See Vulva and other structures
P/S- See cervix, vagina for any deposits, discharge or
growth.
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17.
Bimanual Pelvic Examination
o Tender uterosacral ligament
o Cul-de-sac nodularity found
o Induration of the rectovaginal septum
o Fixed retroversion of the uterus
o Adnexal masses and generalized or localized
pelvic tenderness present
o Uterosacral nodules may be found
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18.
ASRM Classification
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19.
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20.
ASRM staging has poor correlation with
pregnancy rate.
In 2009 new staging system was proposed
called “ Endometriosis Fertility Index. “
EFI is numerical measure of functional
anatomy based on assessment of tubes,
fimbriae and ovaries.
EFI score 0 to 10
(0 – poorest and 10 – the best prognosis).
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21.
Imaging Modalities
 TVS & TRS
 CT SCAN
 MRI
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22.
USG
First line tool for suspected endometriosis
Detects ovarian cysts ( Endometrioma ) and rule
out other causes
 May have role in detection of involvement of
Bladder & Rectum.
Detection of Endometrioma using USG is excellent
with 83 % Sensitivity and 98 % Specificity.
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23.
Classical Appearance :
 Homogenous , Hypoechoic mass with in the
ovary with diffuse low level internal echoes
with hyperechoic foci within the wall.
 Wall nodularity should be differentiated
from hyperechoic foci within the wall.
 95% of endometriomas display low level of
internal echoes.
D/D : Dermoid , Hemorrhagic , Cystic
neoplasm
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24.
TRS :
- To look at Sigmoid for endometriotic infiltrates.
- Rounded or triangular hypoechoic deposits.
- Infiltration of bowel wall is seen as thickening
of Muscularis Propria.
Doppler :
• Better studied in late follicular & early luteal
phase.
• Blood flow in Endometrioma is usually
Pericystic with RI > 0.45.
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25.
CT Scan / MRI
 MRI may detect even smallest of lesions
and distinguish hemorrhagic signal of
endometriotic implants; superior to CT scan in
detecting limits between muscles and abdominal
subcutaneous tissues
 MRI demonstrated to accurately detect
rectovaginal disease and obliteration in more
than 90% of cases when ultrasonographic gel was
inserted in the vagina and rectum
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26.
Sensitivity 90 %
Specificity 98 %
 Major role is to help visualize
laparoscopic blind spots such
as retroperitoneal space and
lesions obscured by dense
adhesions or typical lesions.
DPE is best diagnosed
and located by TRS &
MRI.
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27.
I.V. Urography :
- Serosal deposits are seen at dome of bladder.
- Involvement of Ureter is also seen.
Barium Enema :
Serosal deposits are causing thickening
and fibrosis of Muscularis propria which is
demonstrated as asymmetric narrowing or
eccentric intramural filling defect.
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28.
Histological Diagnosis
• Positive confirms But Negative doesn’t
exclude.
• Visual is usually adequate but histology of any
one lesion is ideal
• In > 4 cm endometrioma & Deep infiltrating
disease – histology should be done to identify
endometriosis and exclude malignancy.
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29.
• Microscopically :
Implants consist of endometrial glands and
stroma with or without hemosiderin laden
macrophages.
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30.
Biochemical Marker
CA - 125
 Cancer Antigen-125, a high molecular weight glycoprotein
expressed on the cell surface of some derivatives of
embryonic coelomic epithelium.
 It is elevated towards the end of the luteal phase and during
menstruation.
 In many other conditions elevated CA-125 concentration
like PID, adenomyosis, uterine leiomyoma, menstruation,
pregnancy, epithelial ovarian cancer, pancreatitis, chronic
liver disease.
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31.
 The result of most studies suggest that CA-
125 is not sufficiently sensitive to identify
lesser stages of endometriosis.
CA-125 is NOT reliable as a
screening test.
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32.
Surgical Diagnosis
“ Diagnostic Laparoscopy is
the Gold Standard
investigation for
Endometriosis…”
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33.
For a definitive diagnosis of endometriosis,
visual inspection of the pelvis at laparoscopy is
the gold standard investigation, unless disease
is visible in the posterior vaginal fornix or
elsewhere…
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34.
 Can classify the extent and severity of disease.
 A double puncture technique is essential.
 The grasper placed through the lower abdomen
sheath permits mobilization of the tube and
ovaries.
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35.
 Inspect the lateral side wall, all ovarian
surface, both sides of the broad ligament,
the bladder, bowel serosa, inferior aspect
of cul-de-sac, evaluation of the
uterosacral ligaments and rectal serosa.
 To avoid under diagnosis it should not
be performed during or within 3 months
of hormonal therapy.
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36.
Findings are…
 Typical “powder-burn or “gunshot” lesions on the
serosal surface of the peritoneum. These lesions
are black, blue or dark brown, nodules or small
cysts containing old hemorrhage surrounded by
variable degree of fibrosis.
 White lesions are predominantly fibromuscular
scarring with scattered glandular and stromal
elements.
 Brown lesions are mainly haemosiderin deposits.
Peritoneal defect and subovarian adhesions
contain endometriosis in 40% -70%.
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37.
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38.
 For ovarian endometriosis- Large ovarian
endometriotic cysts are usually located
on the anterior surface of the ovary and
associated with retraction, pigmentation
and adhesions to the posterior
peritoneum.
 Ovarian endometriotic cyst contain a
thick, viscous dark brown fluid.
(Chocolate fluid)
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39.
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Chocolate cyst– sometimes it is confused with
hemorrhagic corpus luteum cysts and neoplastic cysts.
Biopsy must be done.

40.
Thank you