Endometriosis (from endo, "inside", and metra, "womb")

Definition: is a gynecological medical condition in women in which endometrial-like cells appear and flourish in areas outside the uterine , most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones. These endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle.

Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 5-10% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.

Signs and symptoms Pelvic pain A major symptom of endometriosis is recurring pelvic pain. The pain can be mild to severe cramping that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a woman feels is not necessarily related to the extent or stage (1 through 4) of endometriosis. Some women will have little or no pain despite having extensive endometriosis or endometriosis with scarring. On the other hand, women may have severe pain even though they have only a few small areas of endometriosis. However, pain does typically correlate to the extent of the disease. Symptoms of endometriosis-related pain may include:

dysmenorrhea. painful, sometimes cramps dysmenorrhea  painful, sometimes cramps during menses; pain may get worse overtime (progressive pain), also lower back pains linked to the pelvis chronic pelvic pain – typically accompanied by lower back pain or abdominal pain dyspareunia  – painful sex dysuria  –sometimes painful voiding dragging pain to the legs are reported more commonly by women with endometriosis. Those with sever disease appears to be more likely to report shooting rectal pain. Individual pain areas and pain intensity appears to be un related to area of endometriosis

Other symptoms may be present, including: Constipation chronic fatigue heavy or long menstrual periods with small or large blood clots gastrointestinal problems including diarrhea, bloating and painful defecation extreme pain in legs and thighs back pain mild to extreme pain during intercourse extreme pain with or without the presence of menses premenstrual spotting mild to severe fever headaches depression hypoglycemia (low blood sugar) anxiety

Cause the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other.

Cause 1. Estrogens: Endometriosis is a condition that is estrogen-dependent and thus seen primarily during the reproductive years. In experimental models, estrogen is necessary to induce or maintain endometriosis. Medical therapy is often aimed at lowering estrogen levels to control the disease.

2. Retrograde menstruation: The theory of retrograde menstruation, first proposed by John A. Sampson, suggests that during a woman's menstrual flow, some of the endometrial debris exits the uterus through the fallopian tubes and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as endometriosis. While most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevent implantation and growth of cells from this occurrence. However, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis.

2. Retrograde menstruation: The theory of retrograde menstruation, first proposed by John A. Sampson, suggests that during a woman's menstrual flow, some of the endometrial debris exits the uterus through the fallopian tubes and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as endometriosis. While most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevent implantation and growth of cells from this occurrence. However, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis.

Factors that might cause the tissue to grow in some women but not in others need to be studied, and some of the possible causes below may provide some explanation, e.g., hereditary factors, toxins, or a compromised immune system.

3. Müllerianosis A competing theory states that cells with the potential to become endometrial are laid down in tracts during embryonic development and organogenesis. These tracts follow the female reproductive (Mullerian) tract as it migrates caudally (downward) at 8–10 weeks of embryonic life. Primitive endometrial cells become dislocated from the migrating uterus and act like seeds or stem cells. This theory is supported by fetal autopsy

4. Coelomic Metaplasia: This theory is based on the fact that coelomic epithelium is the common ancestor of endometrial andperitoneal cells and hypothesizes that later metaplasia (transformation) from one type of cell to the other is possible, perhaps triggered by inflammation. This theory is further supported by laboratory observation of this transformation.

5. Genetics: Hereditary factors recognized that daughters or sisters of patients with endometriosis are at higher risk of developing endometriosis themselves; for example, low progesterone levels may be genetic, and may contribute to a hormone imbalance. There is an about 10-fold increased incidence in women with an affected first-degree relative. One study  found a link between endometriosis and chromosome effect . The female siblings of patients with endometriosis the relative risk of endometriosis is about 5.7:1 versus a control population.

6. Immune system: Research is focusing on the possibility that the immune system may not be able to cope with the cyclic of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis toautoimmune disease, allergic reactions, and the impact of toxins.  It is still unclear what, if any, causal relationship exists between toxins, autoimmune disease, and endometriosis.

7. Environment: There is a growing suspicion that environmental factors may cause endometriosis, specifically some plastics and cooking with certain types of plastic containers with microwave ovens. Other sources suggest that pesticides and hormones in our food cause a hormone imbalance.

8. Birth Defect: In rare cases where imperforate hymen does not resolve itself prior to the first menstrual cycle and goes undetected, blood and endometrium are trapped within the uterus of the patient until such time as the problem is resolved by surgical incision. By the time a correct diagnosis has been made, endometrium and other fluids have filled the uterus and fallopian tubes with results similar to retrograde menstruation resulting in endometriosis.

Endometriosis in postmenopausal women does occur and has been described as an aggressive form of this disease characterized by complete progesterone resistance. In less common cases, girls may have endometriosis symptoms before they even reach menarche.

Complications of endometriosis include: Internal scarring Adhesions Pelvic cysts Chocolate cyst of ovaries Ruptured cyst Blocked bowel (bowel obstruction)

Infertility can be related to scar formation and anatomical distortions due to the endometriosis; however, endometriosis may also interfere in more subtle ways: cytokines and other chemical agents may be released that interfere with reproduction. Other complications of endometriosis include bowel and ureteral obstruction resulting from pelvic adhesions. Also, peritonitis from bowel perforation can occur. Ovarian endometriosis may complicate pregnancy by decidualization, abscess and/or rupture, It is the most common adnexal mass detected during pregnancy, being present in 0.52% of deliveries as studied in the period 2002 to 2007. Still, ovarian endometriosis during pregnancy can be safely observed conservatively.

The only way to diagnose endometriosis is by laparoscopy or other types of surgery with lesion biopsy. The diagnosis is based on the characteristic appearance of the disease, and should be corroborated by a biopsy. Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time. possible locations of endometriosis

various stages show these findings: Stage I (Minimal) Findings restricted to only superficial lesions and possibly a few filmy adhesions Stage II (Mild) In addition, some deep lesions are present in the cul-de-sac Stage III (Moderate) As above, plus presence of endometriomas on the ovary and more adhesions Stage IV (Severe) As above, plus large endometriomas, extensive adhesions.

Disadvantages of medicinal interventions Adverse effects are common Not likely to improve fertility Some can only be used for limited periods of time Advantages of surgery Has significant efficacy for pain control. Has increased efficacy over medicinal intervention for infertility treatment Combined with biopsy, it is the only way to achieve a definitive diagnosis Can often be carried out as a minimal invasive (laparoscopic) procedure to reduce morbidity and minimalize the risk of post-operative adhesions 

Disadvantages of surgery Cost Risks are "poorly defined... and probably underestimated." In one study, 3-10% experienced major complications from surgery. Efficacy is questionable. In the same study, substantial short-term pain relief was experienced by approximately 70-80% of the subjects. However, at 1 year follow-up, approximately 50% of the subjects needed analgesics or hormonal treatments  

HEALTH ASSESSMENT HISTORY TAKING/HEALTH HISTORY Ensure the baseline history and identify problem. Midwife must access: - General health and family history of patient. - Age of menarche (first menstruation). - Patient’s last menstrual period (LMP), description of menstrual pattern and flow. - Risk for sexually transmitted disease (STD’s). - Pregnancy history : number of pregnancies, live births, stillborn births, type of fetal abnormalities. - Abortion history. - Drug, allergy, substance abuse, and smoking history. - Symptoms of present disorder, such as painful intercourse or characteristic of vaginal discharge, and duration.

PHYSICAL EXAMINATION Perform the gynecologic examination (pelvic examination), an inspection, and palpation of pelvic reproductive system. Obtains examination gloves, lubricant, several sizes of bivalve speculums and light source. Firstly inspect the external genitalia and adjacent structures, following inspection of the vaginal wall and cervix by using a bivalve speculum. Next, one or two fingers of a lubricated, gloves hand are placed into vagina. Do the vaginal-abdominal palpitation, structures beyond the vaginal orifice are examined. Access the position, size, and contour of the uterus, ovaries, and other pelvic structures. At the end of examination, a gloved finger is inserted into the rectum to palpate the posterior surface of the uterus.

PELVIC EXAMINATION Examination of uterus, vagina, ovaries, fallopian tubes, bladder, and rectum for any changes in their shape or size. Speculum is used to widen the vagina so that the upper part of the vagina and the cervix can be seen

PELVIC ULTRASOUND Sound waves that shows organs and structures in the pelvis; bladder, ovaries, uterus, cervix, and fallopian tubes Abnormalities : small ovarian cysts, leiomyoma, endometrial carcinoma. Evaluation of endometrium : thickness.

TRANSVAGINAL ULTRASOUND (TVS) Procedure used to examine the vagina, uterus, fallopian tubes, ovaries, and bladder. Transducer (probe) is inserted into the vagina that causes sound waves to bounce off organs inside the pelvis. Creates a sonogram.

Diagnostic Investigations HYSTEROSCOPY & ENDOMETRIAL BIOPSY Hysteroscopy is the examination of the whole endometrial cavity, lower segment and cervical canal ; to detect small polyps or sub-mucous fibroids. Hysteroscopy alone (without biopsy) is not very accurate in diagnosing endometrial hyperplasia and carcinoma. Endometrial biopsy or aspirate is to exclude endometrial pathology like hyperplasia, endometrial disorders or malignancies.

Diagnostic Investigations THYROID FUNCTION TEST PROLACTIN LEVEL These tests can rule out hyperthyroidism or hypothyroidism and hyperprolactinemia. These conditions cause ovarian dysfunction leading to possible menorrhagia. LIVER FUNCTION TEST RENAL FUNCTION TEST β-HCG LEVEL

MEDICAL & SURGICAL MANAGEMENT

In endometriosis management the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. In younger women, surgical treatment attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue.

In women who do not have need to maintain reproductive life, hysterectomy and/or removal of the ovaries may be an option; however, this will not guarantee that the endometriosis and/or the symptoms of endometriosis will not come back, and surgery may induce adhesions which can lead to complications.

Treatments for endometriosis in women who do not wish to become pregnant include: Progesterone or Progestins neutralizes and inhibits the growth of the endometrium. Progestins are chemical alternatives of natural progesterone Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.

2. Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach. FDA fertilty device approach

Recently Seasonale was approved to reduce periods to 4 per year Recently Seasonale was approved to reduce periods to 4 per year. Other OCPs have however been used like this off label for years. Continuous hormonal consists of the use of combined oral contraceptive pills eliminates monthly bleeding episodes. FDA fertilty device approach

3. Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes. The nature work of GnRH to stimulate estrogen and proges continous stimulus result in decrease FSH and LH hormone

4. Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH that results in down regulation,inducing  by decreasing-FSH and LH levels. While effective in some patients, they induce unpleasant menopausal symptoms, and over time may lead to osteoporosis. These drugs can only be used for six months at a time. The nature work of GnRH to stimulate estrogen and proges continous stimulus result in decrease FSH and LH hormone

5. Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in the woman's body to prevent or reduce growth of endometriosis. The injection is given in 2 different doses a once a month for 3 month shot or for 6 month shot with the dosage of according to dr. prescription.

6. Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis. NSAIDs Anti-inflammatory. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may be used. NSAID injections can be helpful for severe pain or if stomach pain prevents oral NSAID use.

7. Morphine sulphate tablets (MST) and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called "endorphins". 8. Diclofenac suppository or pill form to reduce inflammation and as an analgesic reducing pain.

 Surgery Procedures are classified as 1. conservative when reproductive organs are retained, semi-conservative when ovarian function is allowed to continue, radical when the uterus and ovaries are removed. removal, excision (called cystectomy) or ablation of endometriosis, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.  

2. Radical therapy in endometriosis removes the uterus (hysterectomy) and tubes and ovaries (bilateral salpingo-oophorectomy) and thus the chance for reproduction. Radical surgery is generally reserved for women with chronic pelvic pain that is disabling and treatment-resistant. Not all patients with radical surgery will become pain-free. 3. Semi-conservative therapy preserves a healthy appearing ovary, and yet, it also increases the risk of recurrence.

For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. neurectomy is more effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the pain extends to the left and right lower quadrants of the abdomen.

Destroy or remove the endometrial tissue. Endometrial destruction or ablation Destroy or remove the endometrial tissue. Performed for women who has been diagnosed with menorrhagia and cannot or do not want to have hysteroscopy procedure. Endometrial ablation destroys a thin layer of the lining of the uterus and stops the menstrual flow. In some women, menstrual bleeding does not stop but is reduced to normal or lighter levels.

Surgical Management

THANKS Dr.Areefa