Endometriosis *Is the presence of endometrial glands and stroma outside the endometrial cavity and walls *Deposits proliferate during the menstrual cycle, brake down & bleed with menstruation, causing local inflammatory reaction *Fibrosis & distortion of the tissue affected with dense scarring. Benign

Endometriosis Hormone dependant Responds to estrogen Regress after menopause, oopherectomy and during pregnancy

Endometriosis Etiology Unknown Theories Retrograde menstruation Coelomic epithelium transformation Lymphatic and vascular spread Genetic and immunologic factors

Endometriosis Epidemiology Disease of reproductive age group Affect 5-15% of women Diagnosed in 20-30% of women investigated for infertility More in women whose first degree relative have the disease Often diagnosed incidentally

Endometriosis High social class women in their thirties and infertile! Can be diagnosed in any type of women and all age groups

Endometriosis Sites More commonly in the dependant part of the pelvis Ovaries 2/3 of women Broad ligament Peritoneal surface of Cul-de-sac and uterosacral ligaments Rectovaginal septum Rectosigmoid colon Distant and laparatomy scars

Endometriosis Pathology Gross Hemorrhagic vesicle Free Papule and later nodule Enclosed White nodules or flattened fibrotic scar Healed Ovarian endometrioma is an enclosed hemorrhagic cyst of variable sizes

Endometriosis Histopathology Active endometrial glands and stroma Blood filled cystic lesions Fibrosis with glands only no stroma Adhesion formation

Endometriosis Symptoms According to site No relation between extent of the disease and severity of the symptoms Often discovered incidentally

Endometriosis Symptoms Female reproductive tract Dysmenorrhea Lower abdominal and pelvic pain Dyspareunia Accident to endometriotic cyst Low back pain Infertility Menstrual irregularity !

Endometriosis Symptoms Urinary tract Cyclical haematuria / dysuria Ureteric obstruction Gastrointestinal tract Dyschezia Cyclical rectal bleeding Intestinal obstruction

Endometriosis Symptoms Surgical scar and umbilicus Cyclical pain and bleeding Lungs Cyclical haemoptysis Haemopneumothorax`

Endometriosis Clinical findings Often Negative Suggested by Thickening and nodularity of uterosacral L. Tenderness in POD Ovarian mass/ masses Fixed retroverted uterus Tender nodule in the cervix, umbilicus or scar

Endometriosis Investigations Ca 125 often elevated Ultrasonography for ovarian cyst MRI

Endometriosis DD All causes of chronic pelvic pain Acute conditions Ectopic pregnancy Acute PID Complicated ovarian cyst Acute appendicitis and other surgical emergencies

Endometriosis Diagnosis Direct visualization of the lesion Laparascopy Laparatomy Histopathology to confirm the diagnosis

Endometriosis Treatment Non-steroidal anti-inflammatory agents Induce Amenorrhea: Pseudopregnancy Induce Amenorrhea: Pseudomenopause Surgery

Endometriosis Treatment Pseudo-pregnancy Combined OCP continuous Cyclical ?? of limited value Side effect Synthetic progestogens: Medroxyprogesterone acetate and dydrogesterone high doses continuous Side effect Levonorgestrel-releasing system reduces dysmenorrhoea and regress POD implants

Endometriosis Treatment Pseudomenopause Danazol androgen derivative 6-9 months Gestrinone, androgen derivative Both drugs have androgenic side effects GnRH agonists Menopausal symptoms, Osteoporosis ? Add back therapy

Endometriosis Treatment Surgery Conservative Young patient, women seeking pregnancy, cysts >3cm in diameter Surgical excision, Laser Radical/Definitive surgery Hysterectomy and BSO

Endometriosis Treatment Certainty of diagnosis Severity of symptoms Extent of the disease Fertility Age Damage to other organs

Endometriosis and Infertility Ovarian function Tubal function Coital function Sperm function Early pregnancy failure

Adenomyosis Endometrial glands deep within the myometrium Unknown etiology Different type of patient and presentation

Adenomyosis Multiparous women Late thirties or early forties Sever spasmodic dysmenorrhea Menorrhagia Bulky uterus Diagnosis often histological on examination of hysterectomy sample

Adenomyosis Treatment Induce amenorrhea Symptoms recur once treatment is stopped Hysterectomy is the only definitive treatment