1. 8th Edition APGO Objectives for Medical Students Endometriosis

2. Rationale Endometriosis is a common problem of women of reproductive age, which may result in pelvic pain, infertility and menstrual dysfunction.

3. Objectives The student will be able to describe: Theories of pathogenesis Symptoms and physical findings Common sites of implants Methods of diagnosis Non-surgical and surgical management

4. Definition Presence of endometrial glands and stroma outside uterine cavity

5. Prevalence - overall 10% Generally only seen in women of reproductive age < 5% postmenopausal Found in 50% if complaint of pelvic pai

6. Risk factors Family history

7. Theories of pathogenesis Coelomic metaplasia (Meyer's Theory) - metaplastic transformation of pelvic peritoneum Ectopic transplantation of endometrium (Sampson’s Theory, 1921) Retrograde menstruation Most likely pathogenesis when coupled with immune defect C. Induction hypothesis - vascular and lymphatic dissemination (Halban’s Theory) Substances released/shed from endometrium induce formation of endometriosis

8. Symptoms (Classic triad - dysmenorrhea, dyspareunia, infertility) Pain Secondary dysmenorrhea Dyspareunia Non cyclic diffuse pain Infertility Abnormal bleeding

9. Physical findings No pathognomonic finding Cul-de-sac nodularity and tenderness Uterosacral nodularity + Palpable adnexal mass Cervix deviated laterally on speculum exam

10. Implantation sites Ovary (most common) Pelvic peritoneum Cul-de-sac Uterosacral ligaments Fallopian tubes Rectosigmoid and bowel

11. Diagnosis Preliminary - history and physical Direct visualization, preferably with biopsy showing glands and stroma or hemosiderin laden macrophages At laparoscopy At laparotomy Other tests Ca125 - not specific nor sensitive Placental protein 14 - increased with deep disease Ultrasound and MRI generally for identification of endometriomas

12. Treatment - Nonsurgical Danazol - causes anovulation and hyperandrogenism, i.e. pseudo menopause, via suppression of LH and FSH Side effects - weight gain, acne, deepening of voice, increased muscle mass Used to be the “gold” standard but, due to side affect profile and newer agents, is used very little. Progestins - suppress gonadotropin release Side effects - abnormal bleeding, depression, fluid retention, nausea Depo MPA (Medroxyprogesterone acetate) Oral contraceptives (often given continuously ﾐ pseudo pregnancy regimen) GnRH agonists

13. Treatment - Surgical Conservative - ablate endometrial implants (vaporize, coagulate, cauterize, excise lesions) Extirpative - hysterectomy with or without salpingo-oophorectomy

14. References Olive DL, Schwartz LB. Medical progress: endometriosis. N Engl J Med 1993;328(24):1759- 1769. Brosens IA. Endometriosis - A disease because it is characterized by bleeding. Am J Obstet Gynecol 1997;176(2):263-267. Mishell DR, ed., Comprehensive Gynecology, 3rd ed., Mosby Publishing Company, St. Louis, MO, 1997. Ryan KJ, ed., Kistner’s Gynecology 6th ed., Mosby Publishing Company, St. Louis, MO, 1995. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

15. Clinical Case Endometrosis

16. Patient Presentation A 28-year-old female presents complaining of the inability to conceive for the past two years. She has never used oral contraceptives; she and her husband have not used any form of birth control for over two years. Her menarche occurred at the age of 12 and her menses became very painful in her late teens. Since, she has had chronic cyclical pelvic pain, which has been getting progressively worse over the years. This pain is incapacitating at time and is usually located in multiple areas (midline abdomen, pelvis and lower back). In addition to the pain, her menstrual periods have become increasingly frequent and heavy. She experiences pain with intercourse that has progressively gotten worse. She denies any non-cyclical vaginal bleeding, discharge and weight loss. She states that her 22-year-old younger sister has always had very painful menses.

17. Patient Presentation Physical exam 4mm hyperpigmented, raised, non-tender nodule in the umbilical area. The pelvic exam showed a fixed, retroverted uterus. The uterosacral ligaments on both sides were nodular and mildly tender. A right adnexal mass was palpated and tender. It was round and approximately 5 cm in diameter in the area of the right ovary. The left ovary was slightly enlarged.

18. Patient Presentation LABS CBC, electrolytes, UA, and TFT’s were normal. Semen analysis revealed 2 ml of semen, >40 million sperm per mL, 70% normal forms and 70% motile. Ultrasound of the abdomen showed an ectogenic cystic mass in the right ovary, which measured 4 cm in diameter. The left ovary was reported as normal.

19. Diagnosis Probable endometriosis with an ovarian endometrium

20. Management Laparoscopy showed an endometrioma of the right ovary and focal implants on the left ovary, which were described as bluish-gray “powder burns.” There were also similar lesions ranging from several millimeters to 2cm on the uterosacral ligaments bilaterally and the anterior cul-de-sac. There were dense adhesions on a portion of the left fallopian tubes and filmy adhesions on the right tube. The endometrioma of the right ovary was resected and the focal lesions were resected or destroyed using electrocautery.

21. Teaching points The appropriate treatment for endometriosis varies widely because of the spectrum of clinical symptoms and the vast differences in the extent of the disease. Treatments, whether expectant, medical or surgical, should be individualized depending on the patient’s symptoms, extent of disease, desire for fertility and other factors. One should consider a laparoscopy in patients to establish the nature and extent, as well as potentially treat, the endometriosis before therapy.

22. Teaching points The revised American Fertility Society’s (AFS) staging system is generally used to stage endometriosis in the infertile patient. In the AFS system, points are assigned for size and depth of implants and for the severity of adhesions in various locations. Stages I through IV are assigned on the basis of points. Management of endometriosis can be guided by the stage of disease and the desire for fertility. Endometrial implants alone may not be enough to cause infertility. A comprehensive cohort study of infertile women showed that endometriosis without adhesions did not alter the cumulative conception rate.

23. Teaching points The increasing appearance of endometriosis (macroscopic implants) in fertile asymptomatic women has led to the suggestion that endometrial implants in the pelvis are, to some extent, to be considered as a physiologic process in menstruating women. The crucial question is at which stage does endometriosis become pathologic and a cause of symptoms so that treatment is indicated. One hypothesis is that endometriosis is a physiological process until recurrent bleeding develops in the ectopic implants, at which time the lesions show progression causing symptoms.