Endometriosis

Gynecology 5th course 1st Obstetrical and Gynecological Clinic MMA

Definition of Endometriosis
presence of endometrial tissue, composed of glands and stroma, at sites outside endometrial cavity most common sites

ovary broad ligament cul-de-sac of Douglas rectovaginal septum laparotomy scars

endometrial tissue responds cyclically to estrogen severity of pain unrelated to extent of disease
There may be more pain associated with active lesions in mild disease than with adhesions in severe disease swelling producing local inflammation

commonly occurs in women in 20s and 30s major cause of infertility

tends not to occur before menarche or after menopause

Theories for Etiology

Sampsons theory of retrograde menstruation Halbans lymphatic spread theory Meyers mullerian metaplasia theory

metaplasia of mesothelial cells into endometrial epithelium under some unidentified influence, such as repeated inflammation

Hematogenous spread

Epidemiology

found equally among all races more likely to occur and progress in women with
early menarche in those with menstrual flow exceeding seven days cycles of less than 27 days years of menstruation uninterrupted by pregnancy family history of endometriosis

Incidence
10-15 % of women of reproductive age 40-50 % of women undergoing surgery for evaluation of infertility average age at diagnosis is 28

Risk factors

Single/nulliparous Early menarche Non-oral contraception Shorter cycle/longer duration of flow Dysplastic naevus syndrome, melanoma

History

most common symptoms

dysmenorrhea dyspareunia (especially on deep penetration) perimenstrual back pain infertility

other symptoms reported

dyschezia (difficulty in defecating) abdominal pain irregular bleeding patterns, especially premenstrual spotting

less common symptoms

urgency in urination hematuria rectal bleeding

Physical Exam Findings

may appear normal if lesions = small & few advanced disease

cervical displacement of 1 cm or more to the left or right of midline bimanual exam: tenderness and nodularity of the uterosacral ligaments and posterior cul-desac(Douglas space) are detected adnexal masses that vary in size, shape, and consistency and may be asymmetric, fixed, cystic, or indurated fixed retroversion of the uterus

Diagnostic Tests
CA-125 elevated (Tumour marker) FBC normal ESR normal Diagnostic laparoscopy

Endometriosis on /in the Ovary

Forms a dark, chocolate cystic mass.

Differential Diagnoses

chronic PID recurrent acute salpingitis hemorrhagic corpus luteum benign or malignant ovarian neoplasm ectopic pregnancy adenomyosis

Asymptomatic diaphragmatic endometriosis

Treatment Plan
psychosocial intervention medications

Danazol (ovarian inhibitor) progesterones combined Oral Contraceptives gonadotropin-releasing hormone agonists (GnRH-a)
Lupron injection qmo x 6 mos Synarel nasal spray bid x 6 mos

surgical interventions: conservative vs. definitive

GnRH analogs
Decreases secretion of gonadotropins Major concerns are

Cost Parenteral administration Potential for accelerated bone mineral loss Hot flushes & hypo-estrogen states

Treatment of pain
NSAIDS: all significantly better than placebo, studies vary which one is best Naproxen >mefanemic acid>aspirin Naproxen=ibuprofen Naproxen only drug with significant SEs