Endometriosis

Definition  Presence of endometrial like tissue (glands/stroma) outside the uterus which induces chronic inflammatory reaction.

Most frequent sites are pelvic viscera & peritoneum out of which most common site is ovary.

Familial in nature

Inheritance occur in a polygenic multi factorial fashion.

Etiology

Exact etiology of endometriosis is unknown.

It is a estrogen dependent disease.

Hypothesis

1.     Retrograde menstruation/ectopic transplantation/ Sampson’s theory –Sampson`s theory .

Most widely recognized & plausible theory on the genesis of endometriosis.

Based on the assumption that endometriosis is caused by the seeding or implantation of endometrial cell by trans tubal regurgitation during menstruation.

2.     Coelomic Metaplasia/ Metaplastic Transformation/ Meyer’s theory 

Both peritoneal and endometrial tissues share a common embryologic precursor the coelomic cell.

Metaplastic transformation of coelomic epithelium into endometrial tissue can occur

3.     Lymphatic or Hematogenous Spread Distant to pelvis/ Hallban’s theory –

Explain the observation of endometriosis in unusual sites such as brain & pleura

Extra pelvic endometriosis - vascular or lymphatic dissemination of endometrial cells.

4.     Direct Transplantation from Tissue Trauma or Surgery

Explain the finding of localized endometriosis cesarean-section scar or episiotomy sites.

Biologically distinct tissue may directly attach to a site accompanied by initiation of localized oncogenic-like cascades leading to implant survival.

5.      Induction theory

            An endogenous undefined biochemical factor can induce undifferentiated           peritoneal cells to develop into endometrial tissue.’

6.  Stem cell may be a source

7. Activation of mullerian cell rest

Risk factors

·        Nulliparous

·        Subfertility

·        Early menarche

·        Non oral contraception

·        Non smoker shorter cycle/longer duration of flow

·        Dysplastic naevus syndrome, melanoma

·        Red hair colour

·        Mullerian anomalis

Sites of endometriosis

Ovaries

Pouch of Douglas

Uterosacral ligament

Broad ligament and round ligament

Recto vaginal septum

Fallopian tubes

The back of the uterus and posterior cul-de-sac

The front of the uterus and the anterior cul-de-sac

Pelvic and back wall

Scar , lungs ,brain ,diaphragm etc…..

It can occur anywhere in the body.

The only site where extra genital endometriosis has not been reported is spleen

Types of lesions

Three primary types of endometriosis are

·        Superficial peritoneal lesion,

·        Ovarian endometrioma(chocolota cyst)

·        Deep infiltrating endometriosis

THE BENJAMIN SIGN: When Basal Body Temperature (BBT) of an adolescent girl, with an endometriotic syndrome, stays high during  the menstrual flow or has up and downs during the same and falls only at the end of it, we should strongly suspect endometriosis and go for a laparoscopy.

Endometriosis and subfertility

Numerous mechanisms :

Decreased tuboovarian motility /adhesions

Ovulatory dysfunction /anovulation/Impaired follicle growth

Luteal insufficiency /Decreased circulatory E2 and progesterone

Luteinized unruptured follicle syndrome

Intraperitoneal inflammation

Deleterious effect on sperm motility

Symptoms

·        Dysmenorrhoea

·        Pelvic pain

·        Infertility

·        Dyspareunia

·        Menstrual irregularities

·        Other cyclic bleeding

Endometriosis in men-

Reported in men undergoing treatment of prostatic cancer with orchidectomy & high dose estrogen therapy

Signs

INSPECTION: Scar endometriosis

PER SPECULUM EXAMINATION: Cervical  endometriosis

BIMANUAL EXAMINATION:

Focal tenderness

Fixed retroverted uterus

Uterosacral nodules

Irregular nodules in the POD

Painful swelling of rectovaginal septum

Unilateral cystic ovarian enlargement if cholate cyst

            “Deeply infiltrating nodules are most reliably detected when clinical examination is performed during menstruation”

Investigation

1.     CA 125

No value as a diagnostic tool as compared to laparoscopy

Useful  to predict the recurrence

2.     TVS

Help in the diagnosis of endometriomas, bladder lesions, deep nodules e.g. on rectovaginal septum

Endometrioma

Cystic mass with  “GROUND GLASS APPEARANCE”

Multiloculated

Hyperechoic, thickened cyst wall

3.     Laparascopy

For definitive diagnosis of endometriosis visual inspection of the pelvis at laparoscopy is gold standard, unless disease is visible in vagina or elsewhere.

Classical lesion are ‘powder burn or gun shot lesion.’ These are black, dark brown or bluish nodules or small cyst containing old hemorrhage.

May be associated with hemosiderin deposit.

Endometrioma (chocolate cyst)

Usually located on anterior surfaced of the ovary .

Diameter < 12cm

Associated with retraction pigmentation and adhesion to posterior peritoneam

Adhesion to pelvic side wall and broad ligament. Associated superficial endometriosis with adjacent puckering on surface of ovary.

Contain tarry,thick chocolate coloured fluid composed of hemosiderin derived from previous intraovarian hemorrhage

Marker of more extensive pelvic and intestinal disease

Histological conformation is necessary

Management of endometriosis

Must be individualized

·        Highly dependent on the wishes of the patient - fertility or contraception

·        Symptom and severity of the disease

·        Location of the disease

Medical treatment

1.     Anaelgesics – NSIADs

2.     Menstrual suppression

Progestin

OCP

Progesterone antagonist

Gestrinone

GnRH antagonist/agonist

Aromatase inhibitors

Surgical treatment

Goal

To excise all visible lesions and associated adhesions

To restore normal anatomy

Laparoscopy is better

Laparotomy – reserve for Advanced stage disease Who cannot go laparoscopy

Fertility is not desired