Endometriosis

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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

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