ENDOMETRIOSIS

Definition Is a condition in which tissues similar to normal endometrium in structure and function are found in sites other than the lining of the uterine cavity.

Factors Influencing Development of Endometriosis Familial,genetic Race Low S.E.C Menstrual factors Delayed child bearing Out flow obstruction Hormones Smoking Immunological factors

Pathogenesis Sampson implantation theory Coelomic metaplasia theory Embryonic cell rests theory Lymphatic and haematogenous dissemination Iotrogenic dissemination

Types Endometriosis interna Endometriosis externa

Symptoms Pelvic pain dysmenorrhoea, dyspareunia, low backache, lower abdominal pain. Menstrual irregularity Infertility Haemoptysis,haematuria,malena

Physical Examination Multiple tender nodules along the uterosacral ligaments and above the post fornix of vagina

Possible Mechanism by which Endometriosis cause Infertility Mechanical factors – Adhesions, scarring, distortion of tubo ovarian relationship – Altered tubal motility

Alteration in peritoneal fluid and local response – Direct toxic effect – Increased phagocytosis of sperms – increased peritoneal fluid PGS,interleukin Alteration in systemic immune response Ovulatory dysfunction

Diagnosis Symptoms and signs USG MRI CA- 125 Laparoscopy

Prophylaxis 1.Tubal patency tests not to be performed after curettage or at the time of menses. 2.Pelvic examination or manipulation should not be performed during menses. 3.Women with family HO endometriosis should complete their family as soon as possible. 4.Coc pills with low oestrogen and strong progesterone should be recommended.

Treatment Depends on: Patients age Future fertility desire Extent of disease Severity of symptoms

Medical Therapy Analgesic Therapy – Nonsteriodal antiinflammatory drugs – Prostaglandin synthesis inhibitory drugs

Hormonal Therapy Pseudo pregnancy by Either daily use of progesterone or combined oral contraceptive pills for Six months

Pseudomenopause by Danazol Acts at the hypothalamic pituitary level and decrease gonadotrophin production. Directly interferes with ovarian steriodogenesis Directly binds to androgenic receptors in the endometriosis and cause its atrophy Side Effects a. Androgenic acne, hirsutism, fatigue, headache. b. Of decreased estrogen levels Hot flushes, sweating, breast atrophy.

Lh Rh Analogue like Buserelin, Goserelin Cause down regulation of pituitary and induce a state of hypogonadotrophic hypogonadism Side Effects Hot flushes, vaginaldryness, dyspareunia & osteoporosis

SURGICAL TREATMENT Type of surgery depends on – Age of patient – Desire for future fertility – Extent of the disease – Symptoms

Minimal endometriosis in young/infertile Encouraged to become pregnant Laparoscopic fulgration Laparoscopic laser With pre and post op Danazol Gn Rh agonist

Moderate To Severe Endometriosis Conservative surgery (CSEL) PSN, myomectomy/ Appendectomy pre and post op hormone suppression ART e.g ET, IVF, GIFT Immunotherapy

Therapy After Completion of Family Total abdominal hysterectomy with bilateral salpingo oophorectomy

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