ENDOMETRI

OSIS
PA R K H M E R M E D I C A L S T U DY
 PLAN
I. Introduction
II. Pathology and istes of involvement
III. Pathogeneses
IV. Clinical manifestation
V. Diagnosis
VI. Associated outcome
 INTRODUCTION
- Is defined as endometrial glands and stroma that occur outside the uterine cavity.
- វាអាចលេចលចញល្ចើនកន្នែ ងដូ ចជា ៖ Bowel, Diaphragm, and pleural cavity.
- Ectopic endometrial tissue and resultant inflammation can cause dysmenorrhea ,
dyspareunia, chronic pain , and infertility.
- Endometriosis is an estrogene-dependent, benign, inflammatory disease that
affects women during their premenarcheal , reproductive , and postmenopausal
hormonal stages.
 PATHOLOGY AND SITES OF
INVOLVEMENT
- Gross and microscopic pathology  similar to eutopic endometrial tissue,
endometriosis lesions contain endometrial glands and stroma –unlike, eutopic
endometrium, however, Endometriosis lesions contain fibrous tissue, blood and
cysts.
- Inflammatory and reactive changes within or adjacent to foci of endometriosis
can also confuse the histologic findings.
- Histologic diagnosis can also be hindered by a small biopsy sample.
- Ovarian cyst, or endometrioma , if formed when ectopic endometrial tissue within
the ovary bleeds and results in a hematoma surrounded by duplicated ovarian
parenchyma.
 PATHOLOGY AND SITES OF
INVOLVEMENT
- Endometriomas typically have fibrotic walls and surface adhesions, are filled with
syrup-like chocolate-colored material, are surrounded by duplicated ovarian
parenchyma; and are lined by endometrial epithelium , stroma and glands.
- Endometrial epithelium and stroma lining the endometrioma can be lost over time
and replaced by granulation tissue and dense fibrous tissue, which makes
histological diagnosis difficult,
 The contents of the cyst ( semi-fluid chocolate-colored material versus watery
fluid ) , presence of adhesions and hemosiderine-filled macrophages ( indicative of
chronic bleeding ) and histologically proven endometriosis at other sites in pelvis
aid.
 PATHOLOGY AND SITES OF
INVOLVEMENT
- Deeply infiltrating endometriosis  solid endometriosis mass situated more than
5 mm deep to the peritoneum.
- DIE  generally is found in the retrovaginal septum , rectum, retrosigmoid colon,
bladder, ureter, and other pelvic fibromuscular structure such as the uterine
ligaments and vagina.
Anatomic sites :
- Most common sites of endometriosis  ovaries , anterior and posterior cul-de-sac
, posterior broad ligaments , uterosacral ligaments, uterus , fallopian tubes,
sigmoid colon and appendix , and round ligaments.
 EPIDEMIOLOGY AND RISK FACTORS
- It is hard to determine cause some women have symptomatic and some is not.
Factors associated with an increased risk of endometriosis include nuliparity ,
prolonged exposure to endogenous estrogen (early menarche before age 11 to 13
years ) , heavy menstrual bleeding , obstruction of menstrual outflow , exposure
to diethylstilbestrol in utero , lower body mas index …
 PATHOGENESIS
 results when ectopic endometrial cells implant , grow and elicit an inflammatory
response.
 endometriosis appears to be multifactorial including ectopic endometrial tissue ,
altered immunity , imbalanced cell proliferation and apoptosis , aberrant
endocrine signaling , and genetic factors. Meta-analysis of 8 genome-wide
association studies has identified at least 6 genomic regions that are statistically
associated with endometriosis.
 CLINICAL MANIFESTATIONS
- Women with endometriosis classically present during their reproductive years
with pelvic pain ( including dysmenorrhea and dyspareunia ) , inferitility , or an
ovarian mass .
- Can incidentally diagnosed during surgery or imaging for other indications.
- The peak prevalence of endometriosis occurs in women 25 to 35 years of age
- Pelvic pain is typically chronic and described as dull , throbbing, sharp , and/ or
burning.
- Additional endometriosis – include bowel and bladder dysfunction , abnormal
uterine bleeding, low back pain , or
 CLINICAL MANIFESTATIONS
chronic fatigue , although these symptoms are less common.
Symptoms :
+ Cohort study including over 600 women , endometriosis identified a visceral
syndrome of 7 syndrome :
 Abdominal pain with no relation to menstruation
 Pain during urination
 Pain during defecation
 Constipation or diarrhea
 Irregular bleeding
 Nausea or vomiting
 Feeling tired or lacking energy
 CLINICAL MANIFESTATIONS
Physical examination :
- Depend upon the location and size of the implants
- Finding suggestive of endometriosis include tenderness on vaginal examination ,
nodules in posterior fornix, adnexal masses , and immobility or lateral placement
of the cervix or uterus.
- Lack of findings does not exclude the disease.
Laboratory : no pathognomonic laboratory finding for endometriosis.
- CA 125 concentration can be elevated in women with endometriosis
 CLINICAL MANIFESTATIONS
Imaging : imaging findings suggestive of pelvic endometriosis include ovarian
cysts ( endometriomas ) , nodules of the rectovaginal septum , and bladder nodules
- These findings are typically seen with tranvaginal ultrasound but can also be
viewed with magnetic resonance imaging ( MRI )
 DIAGNOSIS
- Diagnosed by histologic evaluation of a lesion biopsied during surgery ( typically
laparoscopy )
- A non-surgical diagnosis of endometriosis includes :
 Ultrasonographic finding of ovarian endometrioma
 Visual inspection of the posterior vaginal fornix and biopsy of rectovaginal
lesions.
 Cystoscopic evaluation and biopsy of detrusor lesions, and physical examination
findings of rectovaginal endometriosis that are confirmed with imaging.
 DIAGNOSIS
- Surgical exploration :
 Indication for surgical exploration include diagnosis of persistent pelvic pain that
does not respond to medical therapy , evaluation of severe symptoms that limit
function ,and treatment of anatomic abnormailites , such as bladder lesions
 Surgery always laparoscopy , allows both definitive diagnosis and treatment .
 During laparoscopy => endometriosis appear as raised flame-like patches ,
whitish opacification, yellow-brown discolorations, translucent blebs, or reddish
or reddish-blue irregularly-shaped islands.
 Dense fibrous adhesions signify severe disease.
 DIAGNOSIS
- Laparoscopy is not typically performed during or within 3 months of hormonal
treatment to minimize the risk of under-diagnosis of disease.
- Surgical staging of disease – endoometriosis is surgically staged according to the
revised American society for reproductive medicine scoring system.
 Stage 1 : minimal disease is characterized by isolated implants and no
signification adhesions.
 Stage 2 : mild endometriosis of superficial implants that are less than 5 cm , no
significant adhesions are present
 Stage 3 : moderate disease exhibits multiple implants , both superficial and
deeply invasive.
 DIAGNOSIS
 Stage IV : severe disease is characterized by multiple superficial and deep
implants , including large ovarian endometriomas . Firmly and dense adhesions
are usually present.
 ASSOCIATED OUTCOMES
- Link to cancer  associated with some epithelial ovarian cancers , whether
women with endometriosis are at risk for other types of cancers is unclear.
- Endometriosis had 3 times the risk of clear cell epithelial ovary cancer ( EOC ).
- The risk of malignant transformation of endometriosis has been estimated at 1
percent for premenopausal women and 1 to 2.5 percent for postmenopausal
women.
- Endometriosis –associated EOC appears to develop in younger women and has a
better prognosis than most cases of EOC.
- Artherosclerosis and cardiovascular disease : systemic chronic inflammation and
increased oxidative stress are present in the
 ASSOCIATED OUTCOMES
pathogenesis of both atherosclerosis and endometriosis , an elevated risk of
atherosclerosis and subsequent coronary heart disease has been hypothesized in
women with endometriosis .