ENDOMETRIOSISENDOMETRIOSIS
AYMAN SHEHATAAYMAN SHEHATADepartment of Obstetrics and Gynecology Department of Obstetrics and Gynecology
TANTA UNIVERSITYTANTA UNIVERSITY
Endometriosis Endometriosis
Definition: Definition:
Presence of active functioning endometrial implants Presence of active functioning endometrial implants
outside its normal place i.e uterine cavityoutside its normal place i.e uterine cavity
Histology: Histology:
Endometrial Glands with Stroma +/- Inflammatory Endometrial Glands with Stroma +/- Inflammatory
ReactionReaction
SitesSites
AA(( Extra uterine (external) endometriosisExtra uterine (external) endometriosis it means ectopic endometriumit means ectopic endometrium Pelvic:Pelvic:
CommonlyCommonly » Ovaries (75%)Ovaries (75%) - Uterosacral ligaments - Uterosacral ligaments» Pelvic peritoneum (DP) - Recto‑vaginal septumPelvic peritoneum (DP) - Recto‑vaginal septum
Less commonlyLess commonly -- Rectum, urinary bladderRectum, urinary bladder- Cervix, vagina & tubes- Cervix, vagina & tubes
Extra pelvicExtra pelvic:: Skin, lungs, stomach, eyes, nose, ears, Skin, lungs, stomach, eyes, nose, ears, umbilicusumbilicus
BB(( Uterine (internal) adenomyosisUterine (internal) adenomyosis:: in Myometriumin Myometrium
IncidenceIncidence
Incidence: 0.6-10%Incidence: 0.6-10%
*30-50% of infertility*30-50% of infertility
*52% of chronic pelvic pain*52% of chronic pelvic pain
* Age : 10 - 50 years* Age : 10 - 50 years
Etiology: Etiology: Predisposing FactorsPredisposing Factors
HyperestrogenismHyperestrogenism
aa)) Fibroid & metropathia hemorrhagica. Fibroid & metropathia hemorrhagica.
b)b) Delayed marriage, infertility, nullipara Delayed marriage, infertility, nullipara
c)c) estrogen secreting tumors of the ovary as granulosa & theca cell tumors estrogen secreting tumors of the ovary as granulosa & theca cell tumors
d) d) prolonged estrogen therapy.prolonged estrogen therapy.
Uterine manipulation just before or during menses( IUD, Uterine manipulation just before or during menses( IUD, D&C ,HSG,Intercourse) D&C ,HSG,Intercourse)
Interruption of menstual flowInterruption of menstual flow
*Outflow obstruction (impeforate hymen, vag.septum, Cx.stenosis (impeforate hymen, vag.septum, Cx.stenosis or atrsia)or atrsia)
* Use of tampoons during menses Enviromental pollutionsEnviromental pollutions
Etiology: TheoriesEtiology: Theories
Sampson: “Retrograde Menstruation”Sampson: “Retrograde Menstruation”
Celomic MetaplasiaCelomic Metaplasia( irritating factors transform ( irritating factors transform
derivatives of celom into endometrium)derivatives of celom into endometrium)
Combined regurge / metaplasiaCombined regurge / metaplasia
Hematologic / Lymphatic SpreadHematologic / Lymphatic Spread
Diverticular theoryDiverticular theory (uterine cont. leads to (uterine cont. leads to
dipping of endo. Into myomert.)dipping of endo. Into myomert.)
EtiologyEtiology
Genetic FactorsGenetic Factors (run in families)(run in families)
Immune FactorsImmune Factors (weak (weak immunity leave endomertial immunity leave endomertial fragments in pelvis to grow)fragments in pelvis to grow)
Iatrogenic direct Iatrogenic direct implantation(implantation( at CS scar and at CS scar and Episiotomy scar )Episiotomy scar )
Hormonal theoryHormonal theory
TThe initial genesis of endometriosis based on the he initial genesis of endometriosis based on the presence of hormones, mainly oestrogen.presence of hormones, mainly oestrogen.
Pregnancy causes atrophy of endometriosis through Pregnancy causes atrophy of endometriosis through high progesterone level. high progesterone level.
Regression also follows oophorectomy and irradiation. Regression also follows oophorectomy and irradiation. Endometriosis is rarely seen before puberty and it Endometriosis is rarely seen before puberty and it
regresses after menopause. regresses after menopause. Hormones with antioestrogenic activity also suppress Hormones with antioestrogenic activity also suppress
endometriosis and are used therapeutically.endometriosis and are used therapeutically.
No Single Theory Explains All Cases of Endometriosis
PathologyPathology
SitesSites……….ovaries, pelvic peritonium ……….ovaries, pelvic peritonium Gross picture:Gross picture: Lesions are variable in size ,depth and color Lesions are variable in size ,depth and color
**superficial lesions: multiple,brown or purple(powder burn)
* Fibrosed lesions: (blueberry spots)
* Chocolate cyst: large ,single, filled with dark brown semi fluid
Micoscopic picture:Micoscopic picture: Endometrial Glands with Stroma +/- Inflammatory reactionEndometrial Glands with Stroma +/- Inflammatory reaction
Clinical picture Clinical picture
Clinical picture Clinical picture
Patient characters: age ,parity, family history, age ,parity, family history, associated conditionsassociated conditions
Symptoms: AsymptomaticAsymptomatic Chronic Pelvic Pain.(chemical peritonitis, stretch of perit., PG)Chronic Pelvic Pain.(chemical peritonitis, stretch of perit., PG) Dysmenorrhea (cong., spasmo., ascending)Dysmenorrhea (cong., spasmo., ascending) Deep Dyspareunia (RVF, implants in DP)Deep Dyspareunia (RVF, implants in DP) Low Back Pain (uterosacral lesions) Low Back Pain (uterosacral lesions) Abnormal Uterine Bleeding (menorrhagia, polymenorrhea)Abnormal Uterine Bleeding (menorrhagia, polymenorrhea) Infertility( adhesions, dyspareunia, tubal motility affection)Infertility( adhesions, dyspareunia, tubal motility affection) Pelvic Mass (Endometrioma)Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria,, Hemoptysis, epistaxisMisc: Tenesmus, Hematuria,, Hemoptysis, epistaxis Acute abdomenAcute abdomen
Infertility:Infertility: 30-40% of cases 30-40% of cases
Tubal factorTubal factor Autoimmune Autoimmune mechanismmechanism
Uterine, Uterine, vaginal factorvaginal factor
Ovarian Ovarian factorfactor
Peritubal Peritubal AdhesionsAdhesions
Activated Activated macrophagemacrophage
DyspareuniaDyspareunia
RVF uterusRVF uterus
Anovulation Anovulation due to pelvic due to pelvic congestioncongestion
Altered tubal Altered tubal motility motility (PGs)(PGs)
Sperm Sperm phagocytosisphagocytosis
Implantation Implantation failurefailure
Luteal phase Luteal phase deficiencydeficiency
Impaired Impaired oocyte pick oocyte pick upup
Fertilization Fertilization failurefailure
Increased Increased PGs pelvicPGs pelvic
congestioncongestion
LUFSLUFS
SignsSigns
General ex.General ex.:: pallor, ill health Abdominal ex.:Abdominal ex.:• Pelvi-abdominal swelling• Acute abdomen Vaginal ex:Vaginal ex:• Pelvic tenderness• Fixed, retroverted uterus• Tender uterosacral ligaments or • Enlarged ovaries
Diagnosis Diagnosis
Laparoscopy (“Gold Standard)Laparoscopy (“Gold Standard) LaparotomyLaparotomy Inconclusive: CA-125, Pelvic Exam, Inconclusive: CA-125, Pelvic Exam,
History, Imaging StudiesHistory, Imaging Studies Biopsy histopathology examinationBiopsy histopathology examination Beta-3 protein expression in Beta-3 protein expression in
endometrium endometrium day19-20(absent in day19-20(absent in endometriosis) endometriosis)
Endometriosis
Endometriosis
Endometriosis
DENSE ADHESIONSDENSE ADHESIONS
Ultrasonic diagnosisUltrasonic diagnosis
Sonographic FeaturesSonographic Features : :
Endometritic cysts ,fine homogeneous, uniform, Endometritic cysts ,fine homogeneous, uniform,
granular echoes, anechoic, single or multiple, granular echoes, anechoic, single or multiple,
unilateral or bilateralunilateral or bilateral
On Doppler: no vascularity within the massOn Doppler: no vascularity within the mass
Chocolate cystChocolate cyst
MRIMRI UltrasoundUltrasound
Chocolate cystChocolate cyst
Classification / StagingClassification / Staging
Several Proposed SchemesSeveral Proposed Schemes Revised AFS System: Most Often UsedRevised AFS System: Most Often Used Ranges from Stage I (Minimal) to Stage IV Ranges from Stage I (Minimal) to Stage IV
(Severe)(Severe) Staging Involves Location and Depth of Staging Involves Location and Depth of
Disease, Extent of AdhesionsDisease, Extent of Adhesions
AFS scoring (1985)AFS scoring (1985)Stage1 (1-5), II (6-15), III (16-40), IV (> 40)Stage1 (1-5), II (6-15), III (16-40), IV (> 40)
Treatment: Overall ApproachTreatment: Overall Approach
Recognize Goals: Recognize Goals:
–– Pain ManagementPain Management
–– Preservation / Restoration of FertilityPreservation / Restoration of Fertility Discuss with Patient:Discuss with Patient:
–– Disease may be Chronic and Not CurableDisease may be Chronic and Not Curable
–– Optimal Treatment Unproven or Optimal Treatment Unproven or Nonexistent Nonexistent
Age.Age.
Symptoms.Symptoms.
Stage.Stage.
InfertilityInfertility
TREATMENTTREATMENT CONSIDERATIONCONSIDERATION
Treatment of EndometriosisTreatment of Endometriosis
Management of painManagement of pain– Surgery Surgery
– Medical therapyMedical therapy
Treatment of infertilityTreatment of infertility– SurgerySurgery– Ovulation inductionOvulation induction– Assisted reproductive technologyAssisted reproductive technology
Treatment of PainTreatment of Pain
Medical managementMedical management
– Oral contraceptives, progesterone, Oral contraceptives, progesterone, danazoldanazol
– GnRH agonist with add-backGnRH agonist with add-back
– Aromatase inhibitors - letrozoleAromatase inhibitors - letrozole
– NSAIDNSAID
Management of PainManagement of Pain
Surgical treatment Surgical treatment
– Ablation of endometrial implantsAblation of endometrial implants
– Lysis of adhesions Lysis of adhesions
– Ablation of uterosacral nerves Ablation of uterosacral nerves
– Resection of endometriomasResection of endometriomas
Combined surgical and medical Combined surgical and medical treatmenttreatment
CHOICES OF MEDICAL CHOICES OF MEDICAL THERAPYTHERAPY
Drug group Example Side effects
1 Progestogens Medroxyprogesterone
Duphaston
Norculot
Mood swing
Nausea
bloatedness
2 Danazol
(synthetic androgen)
Danocrine Hoarseness
Hirsuitism, acne
3 Oral contraceptives Any OCPs Weight gain, bloatedness
4 GnRH analogue Zoladex (Goserelin)
Lucrin
Vasomotor symptoms/ osteoporosis
Continuous OCPsContinuous OCPs
COCPs act by ovarian suppression COCPs act by ovarian suppression leading to leading to Pseudopregnancy statePseudopregnancy state
? Minimizes Retrograde Menstruation? Minimizes Retrograde Menstruation Choose OCPs with Least Estrogenic Choose OCPs with Least Estrogenic
Effects, Maximal Androgenic / Progestin Effects, Maximal Androgenic / Progestin Effects (Marvelon)Effects (Marvelon)
ProgestinsProgestins
All progestational agents act by decidualization All progestational agents act by decidualization and atrophy of the endometrium.and atrophy of the endometrium.
MPA 10-30 mg/dayMPA 10-30 mg/day DP 150 mg Semi-MonthlyDP 150 mg Semi-Monthly The LNG-IUS(Mirena)The LNG-IUS(Mirena) GestrinoneGestrinone Dienogest (Visanne) 2 mg/dayDienogest (Visanne) 2 mg/day Side-Effects: AUB, Mood Swings, Weight Gain, Side-Effects: AUB, Mood Swings, Weight Gain,
AmenorrheaAmenorrhea
DanazolDanazol
Weak AndrogenWeak Androgen Suppresses LH / FSHSuppresses LH / FSH Causes Endometrial Regression, AtrophyCauses Endometrial Regression, Atrophy ExpensiveExpensive The recommended dose is 600-800 mg/dThe recommended dose is 600-800 mg/d
Side-Effects: Weight Gain, Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Masculinization, Occ. Permanent Vocal ChangesChanges
GnRH-aGnRH-a
Initially Stimulate FSH / LH ReleaseInitially Stimulate FSH / LH Release Down-Regulates GnRH Down-Regulates GnRH
Receptors–”Pseudomenopause”Receptors–”Pseudomenopause” Goserelin, Triptorelin, Buserelin, Naserelin, Goserelin, Triptorelin, Buserelin, Naserelin,
and leuprolide acetate and leuprolide acetate are the commonly are the commonly used agonists.used agonists.
ExpensiveExpensive Use Limited by Hypoestrogenic EffectsUse Limited by Hypoestrogenic Effects May be Combined with Add-Back therapyMay be Combined with Add-Back therapy
Medical treatmentMedical treatment
Interferons:Interferons:
combination with GnRH have resulted in higher cumulative combination with GnRH have resulted in higher cumulative
pregnancy rates and monthly fecundity ratespregnancy rates and monthly fecundity rates
SERMs:SERMs:
Selective antiestrogenic activity on the endometrium, Selective antiestrogenic activity on the endometrium,
agonist activity on bones and lipoproteinsagonist activity on bones and lipoproteins eg: Tamoxifeneg: Tamoxifen
Indications:Indications:
Mild Endometriosis associated with infertilityMild Endometriosis associated with infertility
Endometrioma >4 cm in diameterEndometrioma >4 cm in diameter
Endometriosis of rectovaginal septum or rectal Endometriosis of rectovaginal septum or rectal
wallwall
Failed Medical therapyFailed Medical therapy
Intolerable side effects of medical therapyIntolerable side effects of medical therapy
SURGICAL MANAGEMENTSURGICAL MANAGEMENT
Surgical treatmentSurgical treatment
Surgical care can be classified as: Surgical care can be classified as: ConservativeConservative when reproductive when reproductive potential is retainedpotential is retainedSemiconservativeSemiconservative when reproductive when reproductive ability is eliminated but ovarian function ability is eliminated but ovarian function is retainedis retainedRadicalRadical when the uterus and ovaries when the uterus and ovaries are removed. are removed.
Surgical Treatment Surgical Treatment (Laparoscopy / Laparotomy)(Laparoscopy / Laparotomy)
Excision / FulgerationExcision / Fulgeration Resection of EndometriomaResection of Endometrioma Lysis of Adhesions, Cul-de-sac ReconstructionLysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve AblationUterosacral Nerve Ablation Presacral NeurectomyPresacral Neurectomy Hysterectomy +/- BSOHysterectomy +/- BSO
EndometriomaEndometrioma
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