Endometriosis
د. نجمه محمودكلية الطبجامعة بغدادفرع النسائية والتوليدDefinition :- Endometriosis defined as presence of endometrial surface epithelium & or endometrial glands & stroma outside the uterine cavity.
Sites of endometriosis:- Ovaries. Fallopian tubes The back of the uterus Within the myometrium & called adenomyosis. broad ligament . Pelvic peritoneum Intestines, most commonly the rectosigmoid Urinary bladder and ureters. Vulva , vagina Lung Abdominal scars.
Ruptured left endometrioma of ovary
Endoscopic pcture of endometriotic spots in POD & uterosacral ligament.Etiology &Pathogenesis:- 1. The implantation theory & menstrual regurgitation . 2. Coelomic metaplasia theory. 3. Lymphatic & vascular dissemination. 4. Genetic & immunological factors.
Ovarian endometriosis:- Endometrioma ( choclate cyst) Rectovaginal endometriosis.
Pathogenesis:- Peritoneal endometriosis:- 1-Red endometriosis. 2- Black endometriosis. 3- White endometriosis.Clinical features :- 1- Asymptomatic. 2- Pelvic pain chronic pelvic pain, congestive dysmenorrhea deep dyspareunia( painful intercourse, dysurea urinary urgency, frequency, and sometimes painful voiding, dyschesia 3- Infertility 4- Features of acute abdomen due to rupture or torsion of endometrioma 5- Menorrhagia & irregular menses.
6- Abdominal & pelvic mass. 7- Cyclic heamaturia , cyclic rectal bleeding. 8- Cyclical pain & bleeding from umbilicus or surgical scars. 9- Cyclical heamoptysis & heamopneumothorax if involve the lungs. 10- O/E fixed RV uterus with hard tender nodules, adnexial mass of endometrioma.
Investigations:- 1) Laprascopy:- it remain the goldstand means of diagnosing the condition it visualize # white thickening scar of endometriosis # fixed RV uterus # burn match stick appearance #adhesion # choclate cyst in the ovaries # heamatosalpinx # it allow take a biopsy from the lesion & give a benefit to determine the extent of the disease & staging , also it allow concurrent therapy at the time of laprascopy in the form of cautery or laser treatment in selected cases.
2) USS:- help in diagnosis of endommetrioma. 3) Ca125 level :- this is a glycoprotien expressed by some epithelial cells of coelomic origin it increase in cases of endometriosis .
4) MRI:- this can detect endometriosis in ovaries or bladder or bowel & rectovaginal septum .
Endometriosis & Infertility:-
30 – 40% of pt with endometriosis have infertility & about 15% of pt with infertility have endometriosis.Mechanism by which endometriosis cause infertility are :-1) Ovarian function2) Tubal function.3) Coital function. 4) Sperm function.5) Early pregnancy failure.6) adhesions.Treatment of endometriosis:-
Medical treatment or surgical treatment 1) Medical treatment :- a) COC P. b) Danazole & gestrinone. c) Progestogens. d) LHRH analogue. e) NSAID.Surgical treatme:nt-
a) Conservative surgery by using laprascopy b) Radical surgery by TAH&BSO in old age pt &who complete her family, postoperative HRT can be used especially in young age women but it is preferred to delayed for 6 months or more to minimize the risk of recurrence.Adenomyosis
# Repeated pregnancy. # vigourous curretage. # endometrial hyperplasia. Pathology:- The uterus is symetrically enlarged , the lesion could be localized or diffused throught the uterine wall , cystic space filled with blood within myometrium on HP exam.