Mamai ppt1

Endometriosis
Fereshteh shabani zonouzi

418İ-3b
Ginekologiya
DEFINITION
DEFINITION
● Presence of endometrial tissue (both glands & stroma) outside the

uterus.
● Tissue is morphologically and functionally similar to endometrial
tissue
● responds to hormones in cyclical manners.
ETIOLOGY
theories 1.
● Sampson’s theory of menstrual regurgitation and implantation (Metastatic
theory)
● Retrograde menstruation ↓ Endometrial fragments are transported to
peritoneal cavity through tubes ↓ Viable cells implant & grow
● Young girls with obstructive anomalies of genital tract often develop
endometriosis.
Cont…
2. Coelomic metaplasia theory:

● Original Coelomic membrane transforms into endometrial tissue.
● Explains endometriosis in ectopic sites.
3. Lymphatic & vascular metastases theory:
● Lymphatic & hematogenous spread of endometrial cells Extensive
communication of lymphatics between uterus, tubes, ovaries, pelvic &
vaginal lymph nodes, kidneys & umbilicus.
4. Genetic factors:
● risk is 7 times more if first degree relative has endometriosis.
4. Immunological factors:
● reduced clearance of endometrial cells due to decreased natural killer cell activity or
decreased macrophage activity.
5. Inflammation:
● endometriosis maybe associated with subclinical peritoneal inflammation
TYPES OF ENDOMETRIOSIS
EXTRA PELVIC
ENDOMETRIOSIS ENDOMETRIOSIS
● Peritoneal ● Scar endometriosis
● Ovarian ● Vaginal endometriosis
● Deep infiltrating ● Thoracic endometriosis
● Urinary tract
● Gastrointestinal tract
CLINICAL PRESENTATION: PAIN
Classical triad: dysmenorrhea, dyspareunia & deep seated pelvic pain.

• Commence before onset of menses & continue throughout the menstrual period. Also has
a cyclical nature.
• Deep dyspareunia due to stretching of involved tissue during intercourse.
• Fixed retroverted uterus or involvement of uterosacrals and rectovaginal septum.
• Dysuria & dyschezia: in extragenital endometriosis
ABNORMAL BLEEDING INFERTILITY
May include premenstrual spotting, Present in majority of the women with
polymenorrhoea & menometrorrhagia. endometriosis. • Advanced disease, adhesions and
fixity results in structural damage to tubes and
ovaries impairs tubo-ovarian mobility. • Ovarian
problems: anovulation, luteinized unruptured
follicle, oocyte maturation defects. • Tubal problem:
altered tubal motility or ovum pick up. • Peritoneal
factors: intraperitoneal inflammation • Sperm
problems: phagocytosis by macrophages,
inactivation by antibodies. • Endometrium: luteal
phase defect, implantation defects
SIGNS & SYMPTOMS
Signs
● Dysmenorrhoea
● Tenderness in cul-de-sac
● Dyspareunia
● Nodularity in cul-de-sac
● Deep seated pelvic pain
● Fixed retroverted uterus • Dysuria • Adnexal tenderness • Dyschezia •
Adnexal masses • Hematuria • Infertility
OTHER SYMPTOMS
● Extrapelvic endometriosis: cyclical rectal bleeding or hematuria.

● Scar endometriosis: cyclical pain and bleeding at scar
● Umbilical endometriosis: present as umbilical mass with cyclical pain.
● Pulmonary endometriosis: cyclical hemoptysis and hemothorax.
TRANSVAGINAL ULTRASOUND SCAN
● Retroverted uterus with obliteration of cul-de-sac & BL complex adnexal masses

maybe suggestive.
● Helps to differentiate endometrial cysts from other complex cysts like dermoids:
_ Endometrial cyst: low level internal echoes with posterior acoustic enhancement –
Ground glass appearance.
- Dermoid: posterior acoustic shadowing d/t presence of bone & teeth in cyst.
● Presence of mural nodule & “pins and needle”.
● Increased in moderate to severe
endometriosis
● Also increased in non-mucinous
epithelial ovarian cancers.
LAPAROSCOPY
● Gold Standard
During laparoscopy, entire pelvis should be examined systematically in

clockwise or counterclockwise direction.
● Aims:
Detection and biopsy of lesions

Staging disease
Concomitant laparoscopic surgical treatment
Endometriosis (laparoscopy)
● INVESTIGATIONS CT & MRI: Identical picture as in
● USG COLOUR DOPPLER FLOW: Increased vascularity
● CYSTOSCOPY: Involvement of bladder
● SIGMOIDOSCOPY: If the women develops bowel symptoms
● ANTIENDOMETRIAL ANTIBODIES: In serum, peritoneal fluid &
endometriotic fluid as well as in normal endometrial tissue TNF:
Raised proportionate to the disease
PERITONEAL LESION CLASSIC LESIONS:
Powder burn or gunshot lesion: black to dark brown nodules consisting of old
hemorrhages surrounded by fibrosis. • Scarring • Adhesions: b/w ovary & broad ligament
and b/w posterior uterus or vagina & sigmoid colon. SUBTLE LESIONS: • Red lesions:
flame like lesions and glandular excrescences. • White lesion: white opacities, yellow
peritoneal patches and circular peritoneal defects.
OVARIAN ENDOMETRIOSIS ENDOMETRIOMA OE CHOCOLATE CYST
Cyst contains thick tarry fluid- chocolate fluid – derived from previous ovarian
hemorrhage. • Adherent to broad ligament and pelvic side wall. SUPERFICIAL
OVARIAN ENDOMETROSIS: • Superficial implants on ovary. • There can be
adhesions to ovarian bed: Sub-ovarian adhesions
DEEP INFILTRATING ENDOMETRIOSIS
Lesions are usually in rectovaginal space. • May involve uterosacral ligaments, cervix,
bowel or ureters. • Lesions cause adhesion and scarring. • Can be felt on pelvic and rectal
examination as tender nodularity.
SCAR ENDOMETRIOSIS: VAGINAL ENDOMETRIOSIS:
Seen at umbilicus, port sites following Occurs in posterior fornix as a continuation of
laparoscopy, abdominal incisions following endometriosis from cul-de-sac. THORACIC
cesarean section and episiotomy scars. • Present ENDOMETRIOSIS: Lungs & thorax maybe
as painful swelling more prominent at involved leading to cyclical hemoptysis &
menstruation. • Cyclical bleeding is rare. hemothorax.
GASTROINTESTINAL TRACT URINARY TRACT:
Frequently involved: sigmoid, rectum, Common symptoms: cyclical hematuria,
iliocaecum & appendix. • Symptoms: dysuria and frequency. • Pelvic ureter &
abdominal pain, disturbed bowel function bladder shows implants obstruction and
& cyclical rectal bleeding. • There maybe hydronephrosis.
pain on defecation. • Superficial implants
maybe seen on serosa.
Treatment
MANAGEMENT
Management of Endometriosis Asymptomatic minimal endometriosis Observe 6-8

months, Investigate infertility Symptomatic cases Drug treatment Minimal invasive
surgery Surgery
DRUG TREATMENT
Combined oral contraceptives:
• Administered intermittently or continuously.
• High Incidence of side effects & risk of thrombus-embolism limit their prolonged use.
• Seasonal OC for 84 days , with 6 days tablet free, reduce the menstrual periods to just four
cycles in a year.
2. Oral progestogens:• Exert an anti-oestrogenic effect and their continuous administration

causes decidualization and endometrial atrophy. • Norethisterone 5.0 – 20.0mg daily or
Dydrogesterone 10 -30mg daily. • This hormone does not prevent ovulation and is suitable
for a woman trying to conceive.
Treatment
● Hormonal birth control therapy

● Progestogen
● Danazol and Gestrinone, supprasive steroid inhibit growth of endometriosis
but their use remains limited as they may cause masculinizing side effects
such as excessive hair growth and voice changes
● Gonadotropin-releasing hormone modulators
● Aromatase inhibitors
DIFFEERENTIAL DIAGNOSIS
● Chronic PID
● Postoperative adhesions
● Old ectopic gestation
● Pelvic congestion syndrome
● Irritable bowel syndrome
● Diverticulitis
● Ulcerative colitis
● Crohn’s disease
THANK YOU

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Endometriosis

Fereshteh shabani zonouzi

● Presence of endometrial tissue (both glands & stroma) outside the

2. Coelomic metaplasia theory:

Classical triad: dysmenorrhea, dyspareunia & deep seated pelvic pain.

● Extrapelvic endometriosis: cyclical rectal bleeding or hematuria.

● Retroverted uterus with obliteration of cul-de-sac & BL complex adnexal masses

During laparoscopy, entire pelvis should be examined systematically in

Detection and biopsy of lesions

Management of Endometriosis Asymptomatic minimal endometriosis Observe 6-8

Combined oral contraceptives:

• Administered intermittently or continuously.

2. Oral progestogens:• Exert an anti-oestrogenic effect and their continuous administration

● Hormonal birth control therapy

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