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Fifth stage
Gynecology
Lec-3
.د
ولدان
16/3/2016
Endometriosis
Objectives of this lecture:
1. To know the definition of endometriosis.
2. To know the theories of pathophysiology.
3. To know the demographic characters of the patients.
4. To know the presentation, diagnosis and management.
Background:
Endometriosis is the presence of endometrial-like tissue outside the uterine cavity, which
induces a chronic inflammatory reaction. It can occur in various pelvic sites such as on the
ovaries, fallopian tubes, vagina, cervix, or uterosacral ligaments or in the rectovaginal
septum.
It can also occur in distant sites including laparotomy scars, pleura, lung, diaphragm, kidney,
spleen, gall bladder, nasal mucosa, spinal canal, stomach, and breast.
Pathophysiology:
Several theories exist that attempt to explain this disease though none have been entirely
proven.
Endometriosis could result from the transport of viable endometrial cells through
retrograde menstruation. Cells flow backwards through the fallopian tubes and deposit on
the pelvic organs where they seed and grow.
Dissemination of endometrial tissue through lymphatic and vascular channels. This may
explain how endometrial tissue can be found at distant locations in the body.
Metaplasia, or the changing from one normal type of tissue to another normal type of
tissue, is another theory.
Frequency:
The prevalence is approximately 6-8%. It is usually diagnosed during laparoscopic surgery
for evaluation of pelvic pain.
Of the surgical population, endometriosis was diagnosed in 25% of women who had a
laparoscopy for pelvic pain and in 20% of women who underwent surgery for infertility.
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Age:
Pelvic endometriosis typically occurs in women aged 25-30 years. Extra pelvic
manifestations of this disorder occur in woman aged 35-40 years. Women younger than 20
years with this disease often have anomalies of the reproductive system. Endometriomas
and symptoms related to them regress significantly after menopause.
History:
• Patients with endometriosis present with a variety of symptoms including the following:
– Dysmenorrhea which may precede the period.
– Heavy or irregular bleeding.
– Pelvic pain.
– Lower abdominal or back pain.
– infertility.
– Dyschezia (pain on defecation) often with cycles of diarrhea and constipation.
– Bloating, nausea, and vomiting.
– Inguinal pain.
– Pain on micturition and/or urinary frequency.
– Pain during exercise.
– One third of women with endometriosis are asymptomatic. Intensity of pain and
discomfort does not correlate with extent of disease because the location and depth
of endometrial implants affect the symptomatology.
Physical examination:
• nonspecific pelvic tenderness.
• Ovarian involvement may present with adnexal tenderness or masses.
• fixed uterine retroversion.
Risk factors:
– Family history of endometriosis.
– Early age of menarche.
– Short menstrual cycles (<27 d).
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– Long duration of menstrual flow (>7 d).
– Heavy bleeding during menses.
– Inverse relationship to parity.
– Delayed childbearing.
– Defects in the uterus or fallopian tubes.
– Hypoxia and iron deficiency may contribute to the early onset of endometriosis.
Diagnosis:
Laparoscopy with biopsy is the only definitive way to diagnose endometriosis. It is an
invasive procedure.
Hallmark findings are the classic powder burn, blue-black lesions.
• The most common sites of involvement found during laparoscopy are the following, in
descending order:
– Ovaries
– Posterior cul-de-sac
– Broad ligament
– Uterosacral ligament
– Rectosigmoid colon
– Bladder
– Distal ureter
Differential diagnosis:
• Chronic salpingo-oopheritis.
• Ovarian cyst, malignant ovarian tumours.
• Small myoma.
• Acute abdomen.
Medical treatment:
NSAID
• Potent analgesics.
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• Reduce severity of dysmenorrhoea & pelvic pain.
• Do not have an impact on disease progression.
Medical therapy for treating endometriosis involves hormonal therapy. Progestins,
combination estrogens/progestins, danazol, and gonadotropin-releasing hormone (GnRH)
agonists are some of the medications used. Patients should not begin a regimen of danazol
or GnRH agonists unless they are monitored by a gynecologist and have a laparoscopically
confirmed diagnosis of endometriosis.
Oral contraceptive pills
• Reduce severity of dysmenorrhea.
• Reduce menstrual blood loss.
• Taken interrupted or continuous.
Danazol, Gestrinone
• both suppress ovarian hormones.
• Both reduce severity of symptoms.
• Treatment courses 3 – 6 months.
• Doses : danazole 400 – 800 mg / d.
gestrinone 2.5 mg twice weekly.
• side effects are androgenic : wt gain, greasy skin, acne.
Progestagens:
• Medroxyprogesterone acetate, dedrogestrone
• Given continuously to simulate psuedodecidualization of the endometrium.
• Requires high doses to be effective.
• Side effects: break through bleeding, wt gain, fluid retention.
Gonadotrophine releasing hormone agonists
• Are equally effective as danazole in relieving severity of disease.
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• Side effects: pseudomenopause.
• Daily intranasal spray.
• Slow release depot for 3 months.
Surgical treatment:
conservative surgerry
• LASER.
• Co2 diathermy.
• Drainage of endometriotic cyst, and destruction of it’s interior.
• Indicated when fertility is desired, & disease is mild to moderate.
Definitive surgery:
• When symptoms are sever.
• When the disease is progressive
• When there is large adhesion.
• When family is complete.
• TAH + BSO.
Adenomyosis
• It is a disorder in which endometrial glands are found deep within the myometrium.
• Patients are usually multioparous, in their late thirties or early forties.
• Present usually with severe congestive dysmenorrhoea menorrhagia.
• On examination the uterus is bulky ,tender.
• USS: altered ecchogenisity in myometrium, similar to uterine fibroid.
• Treatment: danazole, GnRHa.
• TAH.