Gyn 22

• Endometriosis is the presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa
• Endometriosis is not a neoplastic condition, although malignant transformation is possible
• Ectopic endometrial tissues may be found in the myometrium when it is called endometriosis interna or adenomyosis
• Most commonly, ectopic endometrial tissues are found at sites other than uterus and are called endometriosis externa or generally referred to as endometriosis
• Endometriosis is a benign but locally invasive and disseminates widely disease
• Cyclic hormones stimulate growth but continuous hormones suppress endometriosis
• Women with extensive disease may remain asymptomatic whereas a patient with minimal disease may have incapacitating chronic pelvic pain and other symptoms
• Endometriosis is an aggressive, progressive and invasive disease
• Prevalence


  The prevalence of endometriosis has been increasing both in terms of real and apparent
• The real increase is due to delayed marriage, postponement of first conception and adoption of small family norm
• The apparent increase is due to increased use of diagnostic laparoscopy as well as heightened awareness of this disease complex amongst the gynecologists
• The prevalence of endometriosis is about 10–15%
• The prevalence is high amongst the infertile women (30–45%) as based on diagnostic laparoscopy and laparotomy
• Sites of endometriosis


  • Abdominal
  • Extra-abdominal
  • Remote
• Abdominal endometriosis is usually confined to the abdominal structures below the level of umbilicus
• Common extra-abdominal sites of endometriosis

  • Abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy
  • Umbilicus
  • Episiotomy scar
  • Vagina
  • Cervix

  
• Theories to explain the pathogenesis of endometriosis

  • Retrograde menstruation (Sampson's theory, 1927)
  • Coelomic metaplasia (Meyer and Ivanoff)
  • Direct implantation theory
  • Lymphatic and vascular theory (Halban, 1925)
  • Genetic and immunological factors
  • Environment theory
• Not all cases of endometriosis at different sites can be explained by a single theory
• Summary of etiopathogenesis of endometriosis

  • Genetic mutations (familial clustering)
  • Immunological
  • Molecular defects
  • Mechanical (outflow tract obstruction)
  • Environmental toxins (dioxins)
  • Others as described above
• Pathology of endometriosis


  • The endometrium (glands and stroma) in the ectopic sites has got the potentiality to undergo changes under the action of ovarian hormones
  • Proliferative changes are constantly evidenced, the secretory changes are conspicuously absent
  • Cyclic growth and shedding continue till menopause
  • Blood is irritant and it causes dense tissue reaction surrounding the lesion with ultimate fibrosis
  • Deep lesions with penetration >5 mm are more progressive (DIE)
  • Chocolate cyst may also be due to hemorrhagic follicular or corpus luteum cyst or bleeding into a cystadenoma
• Naked eye appearance of pelvic endometriosis

  • Small black dots, the so called 'powder burns' seen on the uterosacral ligaments and pouch of Douglas
  • Fibrosis and scarring in the peritoneum surrounding the implants
  • Red flame-shaped areas, red polypoid areas, yellow brown patches, white peritoneal areas, circular peritoneal defects or subovarian adhesions
• Microscopic appearance of endometriosis

  • Presence of endometrial tissue—both glands and stroma
  • Lining epithelium of the cyst may be absent or flattened (cuboidal) or replaced by granulation tissue
  • Presence of large polyhedral phagocytic cells, laden with blood pigment—hemosiderin (pseudoxanthoma cells)
  • Cyst wall is composed of fibrous tissue and compressed ovarian cortex
• Patient profile in pelvic endometriosis

  • Age is between 30 and 45
  • Mostly nulliparous or have had one or two children, long years prior to appearance of symptoms
  • Infertility, voluntary postponement of first conception until at a late age and higher social status are often related
  • There is often family history of endometriosis
  • Outflow tract obstruction is an important cause when it is seen in teenagers (10%)
• Types of pelvic endometriosis

  • Minimal or mild
  • Moderate
  • Severe or deeply infiltrating endometriosis (DIE)

  
• Symptoms of endometriosis


  • About 25% of patients with endometriosis have no symptom, being accidentally discovered either during laparoscopy or laparotomy
  • Symptoms are not related with extent of lesion
  • Depth of penetration is more related to symptoms rather than the spread
  • Lesions penetrating more than 5 mm are responsible for pain, dysmenorrhea, and dyspareunia
  • Nonpigmented endometriotic lesions compared to the classic pigmented 'powder burns' lesions produce more prostaglandin F (PGF) and hence are more painful
• First conception until at a late age


  Often related to higher social status
• Endometriosis


  Often has a family history
• Outflow tract obstruction


  An important cause when seen in teenagers (10%)
• Pelvic endometriosis


  • Minimal or mild
  • Moderate
  • Severe or deeply infiltrating endometriosis (DIE)

  
• About 25% of patients with endometriosis have no symptom, being accidentally discovered either during laparoscopy or laparotomy
• Symptoms are not related with extent of lesion
• Even when the endometriosis is widespread, there may not be any symptom; conversely, there may be intense symptoms with minimal endometriosis
• Depth of penetration


  More related to symptoms rather than the spread
• Lesions penetrating more than 5 mm are responsible for pain, dysmenorrhea, and dyspareunia
• Nonpigmented endometriotic lesions


  Produce more prostaglandin F (PGF) and hence are more painful compared to the classic pigmented 'powder burns' lesions
• Midline lesions


  More symptom producing
• Degree of pain is not related to the severity of endometriosis
• Dysmenorrhea


  There is progressively increasing secondary dysmenorrhea. The pain starts a few days prior to menstruation; gets worsened during menstruation and takes time, even after cessation of period, to get relief of pain (co-menstrual dysmenorrhea). Pain usually begins after few years pain-free menses. The site of pain is usually deep seated and on the back or rectum
• Cause of pain in dysmenorrhea

  Increased secretion of PGF 2α, thromboxane β2 from endometriotic tissue
• Abnormal uterine bleeding (AUB)


  Menorrhagia is the predominant abnormality. If the ovaries are also involved, polymenorrhea or epimenorrhagia may be pronounced. There may be premenstrual spotting