P.O.C Endometriosis Externa Endometriosis Interna(Adenomyosis)

Definition Presence Of Functioning endometrial glands &stroma outside endometrial lining Presence Of inactive endometrial glands & stroma within myometrium

Incidence Unknown :

•10%:In child bearing period

•20% in patients with chronic pelvic pain

•30% In patients with infertility

Unknown , because the it is only confirmed by histopathological examination after

hysterectomy

Etiology Unknown but may be:

•Retrograde menstrual flow(Sampson’s theory): retrograde passage of endometrium =>Tube=> Peritoneum =>Implantation

•Hematological /lymphatic spread (Halban’s theory) : Explain extra pelvic endometriosis

•Metaplasia of coelemic epithelium(Meyer&Ivanof theory): in to endometrium (By chronic irritation by Retrograde flow)

•Genetic &Immunological theory.

Unknown may be due to presence of endometrial glands within myometrium following :

-↑Estrogen

-Trauma (D&C OR Multiparity)=>Invagination of basal endometrium deep into

myometrium (Cullen diverticular theory)

Predisposing

Factors

↑Estrogen •Age: 25-35Ys

•Parity: Nullipara/Low parity •Socioeconomic state: High

• Race: White

•Family History: Positive

•Age: Late 30s and early 40s

•Parity: Multipara.

•Socioeconomic state: High

•Race: White

•Family History: positive

Pathology •Ovarian Endometriosis: -Mild: Tiny superficial hemorrhagic implants : dark red/brown (Powder burns/gunshot powder) surrounded by adhesions

-Severe: Chocolate cyst(Ovarian endometrioma) ; moderate in size – multiple-lined by endometrium filled with altered blood surrounded by adhesions

•Pelvic endometriosis

-Mild: multiple small dark red cysts : lined by endometrium filled with altered blood surrounded by adhesions

-Severe: Severe adhesions=>Frozen pelvis –fixed RVF

-Diffuse: •Size: symmetrical enlargement, with generalized myometrial thickening

•Shape: Globular

•Capsule: No capsule (Unlike myoma)

•Consistency: Firm

•Cut section: Whorly/granular trabecular pattern with small yellow/brown cysts filled with

fluid/blood

-Localized: to one area similar to myoma.

Clinical

Picture

•Many cases are Asymptomatic discovered accidently by laparoscopy for infertility

•Symptomatic: -Symptoms are suggestive not specific

-Symptoms don’t correlate with the severity of the disease.

-Main symptoms are : Infertility and Pain(Dysmenorrhea-chronic pelvic pain-Dyspareunia –dysurea- Dyschasia- Acute abdominal pain-back ache)

-Other symptoms:GIT-Urinary-Brain-Lung-Umbillicus

•Main Symptoms: -Dysmenorrhea: due to premenstrual swelling OR menstrual bleeding.

-Menorrhagia: due to ↑ Size – vascularity of uterus(↑Estrogen)

•Signs: -Mild cases : Nothing

-More severe cases: *General: nothing(Or anemia) *Abdominal: nothing (Or bluish swelling/scar at umbilicus)

*Local: -Tender swelling at Douglas’s pouch

-Tenderness-nodules at utero sacral ligament by rectal/vaginal examination

-Chocolate cyst: Bilateral fixed illdefined tense tender cystic adenexal swelling with fixed RVF

•Signs: -General: Nothing( Or anemia: bleeding)

-Abdominal: Nothing

-Local: (Bimanual pelvic examination)

*Symmetrically enlarged uterus with premenstrual tenderness (HALBAN’S SIGN)

*localized swelling which is usually diagnosed as myoma

Investigations

-Laparoscopy is the gold standard for diagnosis to confirm-detect extent- follow up for recurrence

•Typical: brown/black pigmentations on peritoneal surface surrounded by adhesions(Powder burns)

•Atypical lesions: Clear vesicle-whitish opacity-red hemorrhagic polypoid.

-Ultra sound and MRI: For follow up and diagnosis of endometriomas not small lesions.(MRI : For deep seated lesions)

-CA-125 in blood( Normal:5-35)

*↑ in endometriosis * Useful for follow up response to ttt - recurrence

-MRI :

*Is the single best choice

*Shows myometrium and Adenomyosis.

-Ultra sound:

*Shows thickened posterior endometrium with localized different echogenicity similar to

myomas.

Management

*Depends on severity-extent – age – desire for fertility:

-Expectant management: •Indications: young female-minimal disease- not desire for fertility

•Aim: ↓Dysmenorrhea- further growth of endometrial tissue

•How: NSAID # PGs=> ↓ Pain

-Medical treatment •Aim : to alleviate symptoms

•How:* Pseudo pregnancy state: Combined contraceptive pills- Progestins

*Pseudo menopause state: Danazole- Gn-RHAnalogue

* Not suitable for adhesions/ chocolate Cyst removal

-Surgical : 1-)Conservative: •Indications: Presence of adhesions/ Chocolate cyst in infertile females(Best choice) to restore anatomy

•How: Laparoscopic adhesolysis – Furgulation- Laser ablation (Excision of cyst) to remove visualized lesions and surrounding adhesions OR

Laparatomy in severe cases (Good hemostasis-gentle manipulation is a must)

•If < 3 cm: Aspiration – irrigation- interior wall vaporization •If > 3 cm remove whole cyst to #recurrence

•Pre-operative GnRH analogue for 3 months is given to ↓ Surface area- vascularity=>Facilitate surgery

•Recurrence risk with preserved ovaries: 15-40%

2-)Extripative( Radical): •Total abdominal hysterectomy with bilateral salpingo-oophorectomy especially if premenopausal with low desire for fertility

•Estrogen replacement therapy is given to relatively young females to alleviate menopausal like symptoms.(May ↑risk of residual endometrial growth)

-Postoperative treatment for infertility:

•Controlled ovarian stimulation protocols.

•Supression of menses for 6 months (By GnRH agonist) followed by ovarian stimulation(HCG-HMG-CC)

•IVF/ ICSI: if adhesions is extensive (Operation may=> Injury of intestine)- Old female>35ys where reproductivity power is sharply ↓

•Moderate dysmenorrhea: NSAID=> #PGs to ↓ pain

•Severe dysmenorrhea with menorrhagia => Hormonal treatment

•How:* Pseudo pregnancy state: Combined c.pills- Progestins

*Pseudo menopause state: Danazole- Gn-RHAnalogue

* Not suitable for adhesions/ chocolate syst remocal

•Localized islands * May be removed selectively( as myomectomy)

*Especially if young with desire for fertility

•If extensive:

*Total abdominal hysterectomy is the single definitive treatment

*Especially if premenopausal with low desire for fertility

*TAH: Is the only way to establish diagnosis with certainty