Subtle Endometriosis

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Subtle Endometriosis

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  • Benha university, Egypt Aboubakr Elnashar
  • History In 1981, Chatman observed that unsuspected E. could be found in peritoneal pockets. In 1986 Jansen & Russel published their observations on non-pigmented E. They concluded that: Visualization of pigment is not necessary to diagnose E. E. in earlier stages of histogenesis may display only non-pigmented lesions. Aboubakr Elnashar
  • Definition (Subtle, atypical, non-pigmented) Endomertiotic lesions that lack the typical black-blue, powder-burn appearance (Jansen & Russel,1986) Aboubakr Elnashar
  • Prevalence Diagnosis of SE increased from 15% in 1986 to 65% in 1988 (Nisole et al,1993). SE are more common than the classic lesions in the adolescents with pelvic pain (Davis et al,1993). The incidence decreases with age (Konincks et al,1991). The most common is white opacification of the peritoneum The least common, but nevertheless characteristic, is the red flame like (Jansen & Russel,1986). Aboubakr Elnashar
  • Classification & morphology Red lesions: 1. Red flame-like lesions, red vesicles or clear vesicles: more commonly affecting the broad ligament & uterosacral ligaments. Histologically: active E surrounded by stroma Aboubakr Elnashar
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  • 2. Glandular excrescences resemble the mucosal surface of the endometrium seen at hysteroscopy Histologically: numerous endometrial glands. 3. Areas of petechial peritoneum or areas with hypervascularization: resemble the peticheal lesions due to manipulation of the peritoneum or to hypervascularization of the peritoneum. They frequently affect the bladder & the broad ligam. Histologically: red blood cells are very rare. Aboubakr Elnashar
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  • White lesions: 1. White opacification: appears as peritoneal scaring or as circumscribed patches often thickened & sometimes raised. Histologically: an occasional retroperitoneal glandular structure & scanty stroma surrounded by fibrotic tissue or connective tissue. 2. Subovarian adhesions. Histologically: connective tissue with sparse endometrial glands Aboubakr Elnashar
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  • 3. Yellow-brown peritoneal patches resembling caf au lait patches. Histologically:similar to those observed in white opacification, but haemosiderin among the stroma cells produces the caf au lait colour. 4. Circular peritoneal defects: frequently occur in areas of the pelvis which overlie loose connective tissue. 80% of peritoneal defects are associated with E, either on the border of the defect or in the defect itself (Donnez et al,1992) Aboubakr Elnashar
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  • NATURE E is a dynamic disease, especially in the early phase, with S lesions emerging & vanishing again(Evers et al,1998). In the end however the peritoneal defense system will prevail & the disease will be contained in the majority of patients. Koninckx et al (1994) considered SE a natural condition occurring intermittently in all women Aboubakr Elnashar
  • Biological activity SE are thought to be more biologically active than typical forms. Vernon et al (1986) demonstrated that red lesions produce twice the amount of PGF than brown lesions. On other hand Muzii et al (2000) found that the biologic activity of red & black lesions was similar The sample size of their study was relatively small to draw firm conclusions Aboubakr Elnashar
  • Natural progression to classic lesions Redwine (1986) showed that: 1.Clear & red lesions occur at a mean age 10 years earlier than the black lesions. 2.A progression of E: from clear to red to white to black, with increasing age. Aboubakr Elnashar
  • Increasing age is associated with a decreasing incidence of SE & increased incidence of typical E, endometrioma & deeply infiltrating E (Koninckx et al,1991). SE progress to pigmented E over time (Jansen & Russel,1986). Second look laparoscopy in untreated patients 6 to 24 months following the initial surgery, documented pigmented lesions in areas previously contained SE Aboubakr Elnashar
  • Prognosis 1. Vascularization is one of the most important factors of growth & invasion of endometrial glands in other tissue (Donnez et al,1989). When compared with typical black lesion, the vascularization was found to be significantly higher in red lesions & significantly lower in white lesions. This change was due to an increase (red) or decrease (white) in the volume occupied by the vessels, as proved by both mean capillary surface area & the ratio of capillaries/stroma surface area.Aboubakr Elnashar
  • So, 1.Red lesions are probably the first stage of E. 2.White lesions could be latent stages of E as suggested by the poor vascularization observed. They are probably non-active lesions which have been quiescent for a long time Aboubakr Elnashar
  • 2. Mitotic index: Mitotic processes permit the maintenance & the growth of peritoneal E. MI is significantly different in typical & subtle E . The absence of mitosis in white lesions proves their low activity (Nisolle et al,1993)Aboubakr Elnashar
  • American Society for Reproductive Medicine (ASRM) classification of E The only difference between the 1985 AFS classification & 1996 ASRM classification is that the latter includes information on the morphologic appearance of the disease. In the new ASRM classification, peritoneal & ovarian implants are categorized into 3 subgroups: 1. Red (red, red-pink & clear lesions) 2. White (white, yellow-brown & peritoneal defects) 3. Black (black & blue lesions).Aboubakr Elnashar
  • The percentage of surface involvement of each implant type (red, white, & black) must be recorded on the opposite form. The new ASRM classification of E is the gold standard to clearly document the extent & location of the disease (Muzii et al,2000) Aboubakr Elnashar
  • Clinical features SE has the same (possibly PG related) symptoms that characterize classic E (Jansen & Russel,1986) 1.IFERTILITY 2.PAIN: dysmenorhea, dysparunia, ch.pelvic pain 3.PREMENSTRUAL BLEEDINGAboubakr Elnashar
  • 1.INFERTILITY: SE is the most common single cause (70%) of unexplained infertility (Propst & Laufer,1999). SE can be etiologically important in infertility. Aboubakr Elnashar
  • 2. PAIN: Acquired deep dysparunia was found in 18% of SE (Jansen & Russel,1986). On other hand Vercellini et al(1996) observed that deep dysparunia was associated only with typical E & not with SE Aboubakr Elnashar
  • Increasing dysmenorrhea suggestive of active E is present in 64% of SE (Tansen & Russel,1986). The number of typical or S implants did not correlate with the severity of dysmenorrhea (Muzii et al,1997). The S forms, however, were considered together & were not categorized into red & white subgroups , as in the new ASRM classification. Recently Muzi et al (2000) found no correlation between the ASRM classification of E & associated dysmenorrhea. White implants are associated with milder pain symptoms than the black or redAboubakr Elnashar
  • Chronic pelvic pain: SE is the most common single cause of chronic pelvic pain not responding to medical treatment (Propst & Laufer,1999). Aboubakr Elnashar
  • 3.PREMENSTRUAL SPOTTING: In the absence of classic E at laparoscopy, premenstrual spotting was highly predictive of SE (Jansen & Russel,1986) . Aboubakr Elnashar
  • Diagnosis The ability to diagnose SE is directly related to the experience & skill of the surgeon(Cook & Rock,1993) 1. Laparoscopy: A. Standard laparoscopy: Negative laparoscopy results do not mean that the patient has no E (Martin,1999) Aboubakr Elnashar
  • B. lactated Ringer or normal saline introduced into the pelvis (Laufer,1997). Laparoscopic visualization of of clear vesicles can be facilitated by the use of the three-dimensional effect of t