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Definition
Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis.
It is a benign but it is locally invasive.
Prevalence
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 this disease complex amongst the gynecologists
Sites
Abdominal: Usually confined to the abdominal structures below the level of umbilicus.
Extra-abdominal: Common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix.
Remote
Pathology
Naked Eye Appearance: The appearance of the lesion depends on the organs involved, extent of lesion and reaction of the surrounding tissues.
Pelvic endometriosis: Small black dots, called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas.
Fibrosis and scarring
Symptoms
Dysmenorrhea (70%)
Abnormal menstruation (20%)
Infertility (40–60%)
Dyspareunia (20–40%)
Chronic Pelvic Pain
Abdominal Pain

Urinary— frequency, dysuria, back pain or even hematuria.
Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena.
Chronic fatigue, perimenstrual symptoms (bowel, bladder).
Hemoptysis (rarely), chest pain.
Surgical scars—cyclical pain and bleeding.
Examination
Abdominal palpation
A mass may be felt in the lower abdomen arising from the enlarged tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility.
Pelvic Examination
Pelvic tenderness, nodules in the pouch of Douglas, nodular feel of the uterosacral ligaments, fixed uterus or unilateral or bilateral adnexal mass of varying sizes
Diagnosis
Bichemical parameters:
Serum CA 125
Monocyte Chemotactic Protein (MCP-1)
Imaging:
TVS - ovarian endometriomas
Endorectal USG - Rectosigmoid endometriosis
MRI - deep infiltrating endometriosis.
Colonoscopy, rectosigmoidoscopy and cystoscopy
Differential Diagnosis
Chronic pelvic infection / symptomatic endometriosis. Laparoscopy is helpful in actual diagnosis.
Ovarian endometrioma / benign ovarian tumor / malignant ovarian.
Ultrasonography or Laparoscopy
Rupture of the chocolate cyst / torsion or rupture of the ovarian tumour, disturbed ectopic pregnancy, appendicitis or diverticulitis.
Complications
Endocrinopathy
Rupture of chocolate cyst
Infection of chocolate cyst
Obstructive features:
Intestinal obstruction
Ureteral obstruction → hydroureter
hydronephrosis → renal infection
Endocrinopathy in Endometriosis
Corpus luteum insufficiency
Luteolysis due to ↑ PGF.
™Luteinized unruptured follicle (LUF)
Anovulation
™Elevated prolactin level
Double LH peak.
Staging
Endometrios is should be staged appropriately.
To predict prognosis.
To choose therapy.
To evaluate the treatment protocol.
The stage is determined by adding specific points given to each.

Definition
Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis.
It is a benign but it is locally invasive.
Prevalence
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 this disease complex amongst the gynecologists
Sites
Abdominal: Usually confined to the abdominal structures below the level of umbilicus.
Extra-abdominal: Common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix.
Remote
Pathology
Naked Eye Appearance: The appearance of the lesion depends on the organs involved, extent of lesion and reaction of the surrounding tissues.
Pelvic endometriosis: Small black dots, called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas.
Fibrosis and scarring
Symptoms
Dysmenorrhea (70%)
Abnormal menstruation (20%)
Infertility (40–60%)
Dyspareunia (20–40%)
Chronic Pelvic Pain
Abdominal Pain

Urinary— frequency, dysuria, back pain or even hematuria.
Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena.
Chronic fatigue, perimenstrual symptoms (bowel, bladder).
Hemoptysis (rarely), chest pain.
Surgical scars—cyclical pain and bleeding.
Examination
Abdominal palpation
A mass may be felt in the lower abdomen arising from the enlarged tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility.
Pelvic Examination
Pelvic tenderness, nodules in the pouch of Douglas, nodular feel of the uterosacral ligaments, fixed uterus or unilateral or bilateral adnexal mass of varying sizes
Diagnosis
Bichemical parameters:
Serum CA 125
Monocyte Chemotactic Protein (MCP-1)
Imaging:
TVS - ovarian endometriomas
Endorectal USG - Rectosigmoid endometriosis
MRI - deep infiltrating endometriosis.
Colonoscopy, rectosigmoidoscopy and cystoscopy
Differential Diagnosis
Chronic pelvic infection / symptomatic endometriosis. Laparoscopy is helpful in actual diagnosis.
Ovarian endometrioma / benign ovarian tumor / malignant ovarian.
Ultrasonography or Laparoscopy
Rupture of the chocolate cyst / torsion or rupture of the ovarian tumour, disturbed ectopic pregnancy, appendicitis or diverticulitis.
Complications
Endocrinopathy
Rupture of chocolate cyst
Infection of chocolate cyst
Obstructive features:
Intestinal obstruction
Ureteral obstruction → hydroureter
hydronephrosis → renal infection
Endocrinopathy in Endometriosis
Corpus luteum insufficiency
Luteolysis due to ↑ PGF.
™Luteinized unruptured follicle (LUF)
Anovulation
™Elevated prolactin level
Double LH peak.
Staging
Endometrios is should be staged appropriately.
To predict prognosis.
To choose therapy.
To evaluate the treatment protocol.
The stage is determined by adding specific points given to each.

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endo.pptx

  1. 1. ENDOMETRIOSIS Dr. Yashika
  2. 2. Definition  Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis.  It is a benign but it is locally invasive.
  3. 3. Prevalence  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 this disease complex amongst the gynecologists
  4. 4. Sites  Abdominal: Usually confined to the abdominal structures below the level of umbilicus.  Extra-abdominal: Common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix.  Remote
  5. 5. Pathology  Naked Eye Appearance: The appearance of the lesion depends on the organs involved, extent of lesion and reaction of the surrounding tissues.  Pelvic endometriosis: Small black dots, called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas.  Fibrosis and scarring
  6. 6. Symptoms  Dysmenorrhea (70%)  Abnormal menstruation (20%)  Infertility (40–60%)  Dyspareunia (20–40%)  Chronic Pelvic Pain  Abdominal Pain
  7. 7.  Urinary— frequency, dysuria, back pain or even hematuria.  Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena.  Chronic fatigue, perimenstrual symptoms (bowel, bladder).  Hemoptysis (rarely), chest pain.  Surgical scars—cyclical pain and bleeding.
  8. 8. Examination Abdominal palpation  A mass may be felt in the lower abdomen arising from the enlarged tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility. Pelvic Examination  Pelvic tenderness, nodules in the pouch of Douglas, nodular feel of the uterosacral ligaments, fixed uterus or unilateral or bilateral adnexal mass of varying sizes
  9. 9. Diagnosis Bichemical parameters:  Serum CA 125  Monocyte Chemotactic Protein (MCP-1) Imaging: TVS - ovarian endometriomas Endorectal USG - Rectosigmoid endometriosis MRI - deep infiltrating endometriosis. Colonoscopy, rectosigmoidoscopy and cystoscopy
  10. 10. Differential Diagnosis  Chronic pelvic infection / symptomatic endometriosis. Laparoscopy is helpful in actual diagnosis.  Ovarian endometrioma / benign ovarian tumor / malignant ovarian. Ultrasonography or Laparoscopy  Rupture of the chocolate cyst / torsion or rupture of the ovarian tumour, disturbed ectopic pregnancy, appendicitis or diverticulitis.
  11. 11. Complications  Endocrinopathy  Rupture of chocolate cyst  Infection of chocolate cyst Obstructive features:  Intestinal obstruction  Ureteral obstruction → hydroureter  hydronephrosis → renal infection
  12. 12. Endocrinopathy in Endometriosis  Corpus luteum insufficiency  Luteolysis due to ↑ PGF.  ™ Luteinized unruptured follicle (LUF)  Anovulation  ™ Elevated prolactin level  Double LH peak.
  13. 13. Staging Endometrios is should be staged appropriately.  To predict prognosis.  To choose therapy.  To evaluate the treatment protocol. The stage is determined by adding specific points given to each.
  14. 14. American Fertility Society scoring system of endometriosis (revised) Peritoneum Endometriosis < 1 cm 1–3 cm > 3 cm Superficial 1 2 4 Deep 2 4 6 Ovary R Superficial 1 2 4 Deep 4 16 20 L Superficial 1 2 4 Deep 4 16 20 Posterior cul-de-sac obliteration Partial Complete 4 40
  15. 15. Ovary Adhesions < 1/3 Enclosure 1/3–2/3 Enclosur e > 2/3 Enclosur e R Filmy 1 2 4 Dense 4 8 16 L Filmy 1 2 4 Dense 4 8 16 Tube R Filmy 1 2 4 Dense 4* 8* 16 L Filmy 1 2 4 Dense 4* 8* 16 * If the fimbriated end of the fallopian tube is completely enclosed, change the point assignment to 16.
  16. 16. Stage Severe Score I Minimal 1-5 II Mild 6-15 III Moderate 16-40 IV Severe >40
  17. 17. Treatment Preventive • To avoid tubal patency test • Avoiding pelvic examination should not be done during or shortly after menstruation. • Married women with family history are encouraged to complete the family. Curative • To minimize pelvic pain and dyspareunia • To improve the fertility • To prevent recurrence
  18. 18. Pelvic Endometriosis  Expectant Management (observation only)  Medical Therapy • Hormones • Others  Surgery • Conservative • Definitive  Combined Therapy • Medical • Surgical
  19. 19. Expectant Treatment  Some form of treatment is often needed regardless of the clinical profile and to arrest the progress of the disease.  In women with minimal to mild endometriosis role of any treatment is controversial.
  20. 20. Case selection for expectant treatment  Minimal endometriosis with no other abnormal pelvic finding  Unmarried  Young married who are ready to start family  Approaching menopause
  21. 21. Protocols for Expectant Management  Observation Ibuprofen 800–1200 mg Mefenamic acid 150–600 mg.  The married women are encouraged to have conception.
  22. 22. Hormonal Treatment Drugs Dose Mechanism Combined estrogen progestogen 1–2 tablets Pseudopregnancy Progestogens Oral • Medroxyprogesterone acetate 10 mg TDS Pseudopregnancy • Dydrogesterone 10–20 mg daily • Norethisterone 10–30 mg daily IM • Medroxyprogesterone 150 mg 3 months IUCD • Levonorgestrel- releasing-IUCD
  23. 23. Danazol 400–800 mg orally in 4 divided doses × 6–9 months Pseudopregn ancy Gestrinone 1.25 or 2.5 mg twice a week × 6–9 months Pseudopregn ancy GnRH analogues Leuprolide 3.75 mg IM monthly × 6 months • Naferelin 200 μg intranasally daily × 6 months • Goserelin 3.6 mg depot IM monthly × 6 months Medical oophorectomy
  24. 24. Surgical Management 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.  Surgery may be conservative or definitive.
  25. 25. Conservative surgery  Done to preserve the reproductive function.  Laparoscopy done to destroy endometriotic lesions by excision or ablation  Laparoscopic uterosacral nerve ablation (LUNA) is done when pain is very severe.
  26. 26. Definitive surgery hysterectomy with bilateral savlpingo- oophorectomy along with resection of the endometrial tissues as complete as possible
  27. 27. Combined Medical and Surgical  Aims at reduction of the size and vascularity of the lesion which facilitate surgery.  The idea of postoperative hormonal therapy is to destroy the residual lesions left behind after surgery and to control the pain.  Duration of therapy is usually 3–6 months preoperatively and 3–6 months postoperatively.
  28. 28. ENDOMETRIOSIS AT SPECIAL SITES  Abdominal scar  Umbilicus  Bladder and ureter  Gut  Cervix and vagina  Lung
  29. 29. Thank you ..

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