65409 Endometriosis Presentation

7/25/2019 65409 Endometriosis Presentation

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Endometriosis

By

Lena Gowharji


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Ann, is a 35 year old lady,complaining of intermittent

abdominal pain, bloating and severdysmenorrhoea !he has a previo"shistory of #B!, b"t recently noticedthat her symptoms are all m"ch

worse in the wee$ before her period %n e&amination she is slim, the

abdomen was distended, non tender,and no masses were felt 'he "ter"s

was anteverted, mobile and noabnormalities were fo"nd in theadne&ia


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Endometriosis

Definition( Benign condition in which)hormone dependant* endometrial glandsand stroma are present outside theuterine cavity and wall.

#ts+ importanceis d"e to its

- .istressing symptomatology

/- Association with infertility 3- #nvasive potential )adjacent organs*

0- .iffic"lty in being diagnosed


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Incidence:

*#ts estimated that 5-51 of women havesome degree of the disease

23 of women with chronic pelvic pain havevis"ali4ed endometriosis

2#ts been noted in 5-51 of women"ndergoing gynaecological laparotomies )an"ne&pected finding in 51 of these cases*


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Age: #t classically presents in n"lliparo"s

infertile women in their 30s.

6owever, it may occ"r at earlier ages)childhood and adolescents* and in s"ch

cases its associated with obstr"ctive genitalanomalies

7ollowing menopa"se, it regresses "nless

estrogen is prescribed 51 of new casesdevelop in that age gro"p


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Pathogenesis:is not f"lly "nderstood6owever

- genetic predisposition

/- imm"nological changes

have been reported to clearly play a role

Several hypotheseshave been "sed toe&plain the vario"s manifestations of thedisease and its vario"s locations

- 'he 8etrograde menstr"ation theory

/- 'he 9"llarian metaplasia theory

3- 'he lymphatic spread theory

0- 'he hematogeno"s spread theory


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! "he retrograde menstruation

theory of Sampson: proposes thatendometrial fragments that are shed

d"ring menstr"ation are transported

thro"gh the fallopian t"bes, thenbecoming implanted and growing in

vario"s intra-abdominal sites )'hese

endometrial fragments are viable and

capable of growing in vivo and in

vitro*


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#! "he mullarian metaplasia theory of $eyer:proposes that endometriosis res"lts from the

metaplastic transformation of peritoneal mesotheli"mto endometri"m "nder the infl"ence of certain"nidentified stim"li

3! "he lymphatic spread theory of %al&an: s"ggests

that the lymphatics draining the "ter"s transportendometrial tiss"e to vario"s pelvic site where itgrows ectopically

2:ndometrial tiss"e has been fo"nd in "p to /1 ofpatients with the disease

'! "he haematogenous spread theory: e&plains thepresence of endometrial tiss"e in distant sites )l"ng,a&illa and forehead*


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(hy don)t all menstruating women developendometriosis

*#t has be fo"nd that the amo"nt of e&pos"re toretrograde menstr"ation and the woman+simm"nological response are most critical

28esearchers have fo"nd differencesin thechemical composition and biological pathwaysof the endometrial cells in women who haveendometriosis in comparison to those whodon+t

'hey have also fo"nd a difference in theinflammatory mediators and growth factors inthe peritoneal fl"id of those with endometriosisin comparison to those witho"t


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Sites of occurrence:

2 9ost commonly fo"nd in the dependant portions ofthe pelvis

- %varies )/ o"t of 3 women with endometriosis*

/- Broad ligament

3- ;eritoneal s"rfaces of the c"l-de-sac

)"terosacral ligaments and post "ently is the recto-sigmoid colon, appendi&,and vesico"terine fold of the peritone"m involved

2 Laparotomy scars esp after c section ormyomectomy or after the "terine cavity has beenentered


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Pathology:

2 'he islands of endometriosis are sensitive toovarian hormones

2+strogen proliferation

28egression of corp"s l"te"m and removal ofestrogen and progesteroneca"ses them toslo"gh

2'hese slo"ghed debris ind"ce a profo"ndinflammatory response that ca"ses significantpain and long term fibrosis


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$acroscopical appearance:

Depends on:site, si4e, time sinceimplantation and day of the menstr"al cycle


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$icroscopically:/ o"t of 0 m"st bepresent in the biopsied specimen toconfirm .&

- endometrial epitheli"m

/- endometrial glands

3- endometrial stroma

0- hemosiderin laden macrophages


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+ndometriosis of the ,vary(

'hese are cysts filled with thic$ chocolatecolo"red fl"id@ which may have a blac$ tarryconsistency sometimes

2 'his characteristic fl"id represents aged,

haemolysed blood and des>"amatedepitheli"m

2 'he glands and stroma lining the cyst+s wallmay be destroyed d"e to an increase in

press"re 'his leaves behind a fibrotic wallwith infiltrating haemosiderin laydenmacrophages


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Risk factors forendometriosis:

?"lliparity

/ #nfertility

3 8eprod"ctive age )"s"ally, late teens

to 0s*

0 A first-degree relative with

endometriosis

5 8eg"lar menstr"al cycle / daysC ;rolonged menses of D or more days


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9any patients are

asymptomatic

%thers "s"ally have no positive

signs at e&amination


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The characteristic triadof symptoms:

- dysmenorrhea

/- dyspare"nia

3- dysche4ia


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Other symptoms:

7emale reprod"ctive tract(7emale reprod"ctive tract(

- pre and postmenstr"al spotting

/- cyclic pelvic pain

3- low sacral bac$pain )especiallypremenst"ally*

0- infertility

5- diminished amo"nt of menstr"al flow

C- ov"latory pain and mid-cycle vaginal

bleeding


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#f the Bladder is involved(#f the Bladder is involved(

- cyclic hemat"ria dys"ria

/- "reteric obstr"ction

#f the rectosigmoid colon is involved@#f the rectosigmoid colon is involved@

- premenstr"al tensm"s or diarrhea

/- obstr"ction


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Signs:

'enderness on biman"al e&amination 'enderness or nod"larity on the posterior

vaginal forni&

Eterosacral ligament tenderness or

nod"larity


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Differential diagnosis


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Diagnosis

6istory and e&amination

;elvic E!

.irect vis"ali4ation of endometrioticlesions

;athological e&amination of biopsy

specimen

:ndometriosis in nota clinical diagnosisF


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Diagnosis

!"spected in afebrile patient with

the characteristic triad(

;elvic pain

/ 7irm, fi&ed tender adne&al

mass

3 'ender nod"larity in c"l-de-sacand "terosacral ligament


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Diagnosis

-A #/

7re>"ently elevated in women

with endometriosis

!ensitivity only /1 to 31

?ot "sed to diagnose

endometriosis


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Diagnosis

Definitive diagnosis is generallymade &y:


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Diagnosis

(hat do endometriosis lesions loo1 li1e +


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Diagnosis

Enfort"nately, even the most e&perienceds"rgoen may fail to identify endometriosisimplants beca"se(

'he older implants may have a very s"btleapperance

'he deeper infiltration lesions may not bevisible at the s"rface

Biopsy of s"specio"s lesions improvesdiagnosis acc"racy


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Staging

American Society of 2eproductive

$edicine -AS2$

:mploys a staging protocol in anattempt to correlate

7ertility potential with a >"antified stage

of endometriosis


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Staging

#nitially started to be based on(

- !ite of involvement

/- e&tent of vis"ali4ed disease

And was modified to incl"de(

.escription of the color of the lesions

;ercentage of s"rface involved in eachlesion type

9ore detailed description of anyendometriosis


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#f the fimbriated end of fallopian t"be is completelyenclosed, change the point assignment to C

.enote appearance of s"perficial implant type as

8:. I)8*, red, red-pin$, flameli$e, vesic"larblobs, clear vesiclesJ

H6#': I)H*, opicifications, peritoneal defect,yellow-brownJ

BLA


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Treatment

?o treatment

/ ?on-hormonal treatment

3 6ormonal treatment0 !"rgical treatment

5 8adiological treatment


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I. No treatment

#f small symptom less lesions

;atient observed M e&amined

every C months


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II. Non-hormonaltreatment

#f small lesions with mild symptoms

Analgesics are given for pain

;rostaglandin inhibitors )napro&en,ib"profen* are given for pain and

menorrhagia


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III. Hormonaltreatment

Indications:

!evere symptoms with small pelvis lesions

/ 8ec"rrence of symptoms after conservatives"rgery

3 9ay be given for a short time )C-/ wee$s*before s"rgery to ma$e dissection easier

0 After conservative s"rgery to allow anyresid"al lesion to regress

5 Hhen operation is contraindicated orref"sed by the patient


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. !se"do pregnancy

%v"lation and menstr"ation are inhibitedfor N months )C-D months* "sing acombined %


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#. !se"do menopa"se

Danaol: given orally 0-D mgday for C-N months Hea$ synthetic androgen !ide effects(

Androgenic effects( acne, male alopecia, hirs"tism, hoarseness ofvoice M hypertrophy of clitoris

/ 6ypo-oestrogenic effects( hot fl"shes, sweating, atrophy of

breasts, atrophic vaginitis, dry vagina, dyspare"nia M decreasedlibido

3 Anabolic effects( weight gain M edema

0 9etabolic effects( impaired gl"cose tolerance, increased ins"linre>"irements in diabetic cases, hepatic dysf"nction Bloodpress"re may be elevated

5


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#. !se"do menopa"se

4n2% -agonist: ?afarelin )synarel*( intranasally "sing a

nasal spray, / micrograms twice daily

Goserelin )4olade&*( 3C mg injected !

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65409 Endometriosis Presentation