2. Definition: Endometriosis is the presence
of endometrial tissue (glands and stroma)
outside the normal uterine cavity
Incidence:
5-10% in general population.
20-40% in infertile women.
6. Aetiology
1. Tubal regurgitation theory of Sampson.
2. DiverticuIar theory of Cullen.
Endometrial glands grow deeply into the
myometrium in the form of diverticula. The
deep portions separated from the surface
endometrium forming areas of endometriosis
between the muscle fibers.
3. Serosal metaplasia theory of Mayer. The
peritoneum and uterine mucosa have the same
embryonic origin (coelomic epithelium), so the
peritoneum can undergo metaplasia into
endometrial tissue.
7. 4. The induction or combined theory of
Lavender. The regurgitated menstrual
fragments stimulate the coelomic epithelium to
undergo metaplasia.
5. Halban theory. Fragments of endometrium
may spread by lymphatics or veins to reach
any part of the body.
6. Implantation theory. Implantation of
endometrial tissue in abdominal scars after
uterine surgeries as myomectomy or CS
7. Immunological theory. Failure of the
immune system to eradicate endometrial
implants.
8. Genetic factor: certain gene in
Chromosome 17
8.
9. PREDISPOSING FACTORS:
1. Hyperoestrinism
2. Delayed marriage and infertility
3. Cervical obstruction due to
stenosis
4. Hysterosalpingography and
curettage
10. PATHOLOGY OF THE COMMON
LESIONS OF ENDOMETRIOSIS:
1. Endometriosis of the ovaries. The
affected ovary is enlarged, irregular, and
surrounded by adhesions. The tunica
albuginea is thickened and the ovary
contains one or more cysts filled with dark
brown blood and lined by endometrium.
These are called "chocolate cysts"
14. 14
This is a section through an enlarged 12 cm ovary to
demonstrate a cystic cavity filled with old blood typical
for endometriosis with formation of an endometriotic, or
"chocolate", cyst.
15. 2.Endometriosis of pelvic peritoneum
. A- Typical endometriosis: The lesion appears
as dark-brown, black, or bluish nodules or
small cysts containing old blood, and
surrounded by a variable degree of adhesions.
The lesions look like tobacco stains or (gun
shot).
B- Atypical Endometriosis: The lesion
appears red implants, clear vesicles, or white
(scarred areas).
22. CLINICAL PICTURE
Age. Most common between 30 and 40 years..
Parity. Nullipara or low parity
Social and economic state. More in higher
classes. (disease of the rich). due to late
marriage and late childbearing.
Genetic factor. There is a familial tendency to
develop endometriosis. Certain genes on
chromosome 17 are related to endometriosis.
Race. More in white women.
23. Symptoms
Asymptomatic
Dysmenorrhoea (crescendo)
Chronic pelvic pain and backache
(congestion, adhesion, PGs and affection of
uterosacral ligament )
Dyspareunia (deep)
Acute abdomen (Rupture of a chocolate cyst
)
Endometriosis of urinary bladder
Endometriosis of rectum
Endometriosis of umbilicus and abd scars
24. Infertility and endometriosis
Ovarian. Anovulation -LUF or LFD
Tubal. Peritubal adhesions interfere with the
"pick up" mechanism of the ovum also the
prostaglandins affect tubal motility
Uterine, due to retroversion.
Vaginal, due to dyspareunia.
Autoimmune mechanism. Prostaglandins
stimulate macrophages which phagocytose the
sperms and release cytokines which may be
toxic to the gametes.
25. Signs
1. The vulva, vagina, and cervix should be
inspected for any sign of endometriosis.
2. Ovarian endometriosis. It is bilateral in
about 50% of cases. The ovaries are felt as
cystic tender masses which are fixed behind
the uterus in Douglas pouch.
3. Endometriosis of the pelvic peritoneum.
Multiple small firm tender nodules are felt
through the posterior vaginal fornix. Similar
nodules may be felt in the region of the
uterosacral ligaments or rectovaginal septum
or on the posterior surface of the uterus.
26. INVESTIGATIONS
Ultrasonography.
Laparoscopy (Gold standard).
MRI
Cystoscopy, proctoscopy or
sigmoidoscopy
Histopathological examination of nodules
excised from the umbilicus, abdominal scar.
Cancer antigen 125 (normal level 8-22U/ml)
31. American Fertility Society
Score 1-5= Mild = Stage I
Score 6-15 =Moderate = Stage II
Score 16-30 =Severe = Stage III
Score >30 =Extensive = Stage IV
Stage 0 = Microscopic endometriosis
(only diagnosed by laparoscopy)
32.
33. TREATMENT
I. No Treatment
Small Asymptomatic lesions require no
treatment, but the patient is kept under
observation and examined every 6 months.
II. Non Hormonal Treatment
For small lesions with mild symptoms.
Analgesics are given for pain as
(Prostaglandin inhibitors naproxen, ibubrufen)
34. III Hormonal Treatment
Indications
1. Small lesion.
2. Recurrence after conservative surgery.
3. Preoperative for 3 months to decrease
size.
4. Postoperative for residual lesions.
5. When operation is contraindicated or
refused by the patient.
35. Aim of the hormonal therapy
(A) Pseudopregnancy :
1. Combined contraceptive pills (6 - 18
months average 9months) to inhibit
ovulation and atrophy of ectopic glands
2. Progesterone (to avoid oestrogen's side
effects as Depo medroxy progesterone
acetate (DMPA) can be given in a dose of
150 mg IM every I - 3 months
36. (B) Pseudomenopause (induction of
amenorrhoea) by:
1. Danazol (400-800 mg/day for 6-9 months)
2. Gn RH analogues (can be given by daily
nasal spray or intramuscularly or subcutaneously
every 4 weeks for 6 months )
3. Gestrinone (1.25-2.5 mg twice weekly for 6-
9 months )
4. Mifepristone (50 mg/day for 6 months
37. Add-back therapy for women
undergoing long-term therapy with
GnRH (> 6 months)
- Add-back regimens: small dose of
estrogen to prevent osteoporosis
38. AROMATASE INHIBITORS
The use of aromatase inhibitors for medical
management of endometriosis is still
experimental and is based on the observation
that endometriotic lesions express the enzyme
aromatase and are able to make their own
estrogen, even in the absence of gonadotropin
stimulation.
39. Aromatase Inhibitors
Blocking the aromatase enzyme in
extraovarian sites that suppress the
conversion of androstenedione and
testosterone to estrogen.
2.5 mg orally 4 times daily 6 months
40. IV- Surgical treatment
INDICATIONS
A. Patients with pelvic pain not respond to
medical therapy
B. who have an acute adnexial torsion or
ovarian cyst rupture)
C. who have severe invasive disease involving
the bowel, bladder, ureters, or pelvic nerves
D. Patients with infertility and associated
factors
42. 1-Conservative surgery
Indicated in young age need future
fertility
1-Remove all areas of endometriosis.
2-Ventrosuspcnsion by plication of round
ligaments or uterosacral ligaments is done
to correct retroversion.
3-Presacral neurectomy to reduce severe
dysmenorrhoea.
43. Approach : Laparoscopy or laparotomy
Tools: Laser or diathermy can be used to
vaporize or excise areas of endometriosis.
Precaution: In infertile women
microsurgical technique should be used
to minimize postoperative adhesions
44. 2. Radical Surgery
Indications: Patient is above 40 years no
need for further fertility.
Type of surgery: Total abdominal
hysterectomy and bilateral salpingo-
oophorectomy.
45. V. Radiological Treatment
Indications:
1- Patients above 40 in whom operation
cannot be done as in case of wide spread
pelvic endometriosis (frozen pelvis)
2- Endometriosis of the rectovaginal septum
which is difficult to excise surgically.
Method :
Induction of artificial menopause by external
pelvic radiation cures the condition by causing
atrophy of endometrial tissue.
46. ADENOMYOSIS
Definition:
It means the presence of endometrial tissue
(glands and stroma) embedded in
myometrium.
Etiology: The exact etiology is unknown but it
can be explained by the Cullen diverticular
theory.
Types: Diffuse or localized
DD: of localized type is Fibroid
47.
48. CLINICAL PICTURE
- Age. Most cases are seen in patients aged 40-
50 years.
- Parity. Most of the cases (80%) are parous
women.
- Social and economic state. More common
among the lower classes.
- Associated lesions. Fibroids (in 50% of
cases),
49. SYMPTOMS
30-40% are asymptomatic
Menorrhagia.
(a) Increased vascularity of the uterus;
(b) Increased surface area of the endometrium;
(c) The presence of endometrial hyperplasia;
(d) Impaired myometrial contractions caused
by the presence of ectopic endometrium.
Dysmenorrhoea
50. SIGNS
1- In Diffuse type :
The uterus may be slightly symmetrically
enlarged, firm and tender. It rarely exceeds the
size of 12 weeks pregnancy.
2- In localized type: The uterus is
asymmetrically enlarged due to a localized
area of endometriosis.
INVESTIGATIONS
- Ultrasonography - MRI -Histological ex.
After hysterectomy.
51. TREATMENT
1. Medical treatment. Analgesics for
dysmenorrhoea. Antiprostaglandins improve both
dysmenorrhoea and menorrhagia.
2. Severe menorrhagia is treated by dilatation and
curettage.
3. Gonadotrophin releasing hormone analogues
lead to amenorrhoea and decrease in uterine size.
However, the effect is temporary and the uterus
returns to its original size with the same symptoms
after cessation of therapy.
4. Hysterectomy is the definite treatment.
