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Endometriosis
By
Lena Gowharji
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Ann, is a 35 year old lady,complaining of intermittent
abdominal pain, bloating and severdysmenorrhoea !he has a previo"shistory of #B!, b"t recently noticedthat her symptoms are all m"ch
worse in the wee$ before her period %n e&amination she is slim, the
abdomen was distended, non tender,and no masses were felt 'he "ter"s
was anteverted, mobile and noabnormalities were fo"nd in theadne&ia
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Endometriosis
Definition( Benign condition in which)hormone dependant* endometrial glandsand stroma are present outside theuterine cavity and wall.
#ts+ importanceis d"e to its
- .istressing symptomatology
/- Association with infertility 3- #nvasive potential )adjacent organs*
0- .iffic"lty in being diagnosed
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Incidence:
*#ts estimated that 5-51 of women havesome degree of the disease
23 of women with chronic pelvic pain havevis"ali4ed endometriosis
2#ts been noted in 5-51 of women"ndergoing gynaecological laparotomies )an"ne&pected finding in 51 of these cases*
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Age: #t classically presents in n"lliparo"s
infertile women in their 30s.
6owever, it may occ"r at earlier ages)childhood and adolescents* and in s"ch
cases its associated with obstr"ctive genitalanomalies
7ollowing menopa"se, it regresses "nless
estrogen is prescribed 51 of new casesdevelop in that age gro"p
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Pathogenesis:is not f"lly "nderstood6owever
- genetic predisposition
/- imm"nological changes
have been reported to clearly play a role
Several hypotheseshave been "sed toe&plain the vario"s manifestations of thedisease and its vario"s locations
- 'he 8etrograde menstr"ation theory
/- 'he 9"llarian metaplasia theory
3- 'he lymphatic spread theory
0- 'he hematogeno"s spread theory
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! "he retrograde menstruation
theory of Sampson: proposes thatendometrial fragments that are shed
d"ring menstr"ation are transported
thro"gh the fallopian t"bes, thenbecoming implanted and growing in
vario"s intra-abdominal sites )'hese
endometrial fragments are viable and
capable of growing in vivo and in
vitro*
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#! "he mullarian metaplasia theory of $eyer:proposes that endometriosis res"lts from the
metaplastic transformation of peritoneal mesotheli"mto endometri"m "nder the infl"ence of certain"nidentified stim"li
3! "he lymphatic spread theory of %al&an: s"ggests
that the lymphatics draining the "ter"s transportendometrial tiss"e to vario"s pelvic site where itgrows ectopically
2:ndometrial tiss"e has been fo"nd in "p to /1 ofpatients with the disease
'! "he haematogenous spread theory: e&plains thepresence of endometrial tiss"e in distant sites )l"ng,a&illa and forehead*
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(hy don)t all menstruating women developendometriosis
*#t has be fo"nd that the amo"nt of e&pos"re toretrograde menstr"ation and the woman+simm"nological response are most critical
28esearchers have fo"nd differencesin thechemical composition and biological pathwaysof the endometrial cells in women who haveendometriosis in comparison to those whodon+t
'hey have also fo"nd a difference in theinflammatory mediators and growth factors inthe peritoneal fl"id of those with endometriosisin comparison to those witho"t
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Sites of occurrence:
2 9ost commonly fo"nd in the dependant portions ofthe pelvis
- %varies )/ o"t of 3 women with endometriosis*
/- Broad ligament
3- ;eritoneal s"rfaces of the c"l-de-sac
)"terosacral ligaments and post "ently is the recto-sigmoid colon, appendi&,and vesico"terine fold of the peritone"m involved
2 Laparotomy scars esp after c section ormyomectomy or after the "terine cavity has beenentered
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Pathology:
2 'he islands of endometriosis are sensitive toovarian hormones
2+strogen proliferation
28egression of corp"s l"te"m and removal ofestrogen and progesteroneca"ses them toslo"gh
2'hese slo"ghed debris ind"ce a profo"ndinflammatory response that ca"ses significantpain and long term fibrosis
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$acroscopical appearance:
Depends on:site, si4e, time sinceimplantation and day of the menstr"al cycle
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$icroscopically:/ o"t of 0 m"st bepresent in the biopsied specimen toconfirm .&
- endometrial epitheli"m
/- endometrial glands
3- endometrial stroma
0- hemosiderin laden macrophages
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+ndometriosis of the ,vary(
'hese are cysts filled with thic$ chocolatecolo"red fl"id@ which may have a blac$ tarryconsistency sometimes
2 'his characteristic fl"id represents aged,
haemolysed blood and des>"amatedepitheli"m
2 'he glands and stroma lining the cyst+s wallmay be destroyed d"e to an increase in
press"re 'his leaves behind a fibrotic wallwith infiltrating haemosiderin laydenmacrophages
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Risk factors forendometriosis:
?"lliparity
/ #nfertility
3 8eprod"ctive age )"s"ally, late teens
to 0s*
0 A first-degree relative with
endometriosis
5 8eg"lar menstr"al cycle / daysC ;rolonged menses of D or more days
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9any patients are
asymptomatic
%thers "s"ally have no positive
signs at e&amination
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The characteristic triadof symptoms:
- dysmenorrhea
/- dyspare"nia
3- dysche4ia
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Other symptoms:
7emale reprod"ctive tract(7emale reprod"ctive tract(
- pre and postmenstr"al spotting
/- cyclic pelvic pain
3- low sacral bac$pain )especiallypremenst"ally*
0- infertility
5- diminished amo"nt of menstr"al flow
C- ov"latory pain and mid-cycle vaginal
bleeding
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#f the Bladder is involved(#f the Bladder is involved(
- cyclic hemat"ria dys"ria
/- "reteric obstr"ction
#f the rectosigmoid colon is involved@#f the rectosigmoid colon is involved@
- premenstr"al tensm"s or diarrhea
/- obstr"ction
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Signs:
'enderness on biman"al e&amination 'enderness or nod"larity on the posterior
vaginal forni&
Eterosacral ligament tenderness or
nod"larity
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Differential diagnosis
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Diagnosis
6istory and e&amination
;elvic E!
.irect vis"ali4ation of endometrioticlesions
;athological e&amination of biopsy
specimen
:ndometriosis in nota clinical diagnosisF
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Diagnosis
!"spected in afebrile patient with
the characteristic triad(
;elvic pain
/ 7irm, fi&ed tender adne&al
mass
3 'ender nod"larity in c"l-de-sacand "terosacral ligament
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Diagnosis
-A #/
7re>"ently elevated in women
with endometriosis
!ensitivity only /1 to 31
?ot "sed to diagnose
endometriosis
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Diagnosis
Definitive diagnosis is generallymade &y:
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Diagnosis
(hat do endometriosis lesions loo1 li1e +
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Diagnosis
Enfort"nately, even the most e&perienceds"rgoen may fail to identify endometriosisimplants beca"se(
'he older implants may have a very s"btleapperance
'he deeper infiltration lesions may not bevisible at the s"rface
Biopsy of s"specio"s lesions improvesdiagnosis acc"racy
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Staging
American Society of 2eproductive
$edicine -AS2$
:mploys a staging protocol in anattempt to correlate
7ertility potential with a >"antified stage
of endometriosis
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Staging
#nitially started to be based on(
- !ite of involvement
/- e&tent of vis"ali4ed disease
And was modified to incl"de(
.escription of the color of the lesions
;ercentage of s"rface involved in eachlesion type
9ore detailed description of anyendometriosis
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#f the fimbriated end of fallopian t"be is completelyenclosed, change the point assignment to C
.enote appearance of s"perficial implant type as
8:. I)8*, red, red-pin$, flameli$e, vesic"larblobs, clear vesiclesJ
H6#': I)H*, opicifications, peritoneal defect,yellow-brownJ
BLA
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Treatment
?o treatment
/ ?on-hormonal treatment
3 6ormonal treatment0 !"rgical treatment
5 8adiological treatment
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I. No treatment
#f small symptom less lesions
;atient observed M e&amined
every C months
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II. Non-hormonaltreatment
#f small lesions with mild symptoms
Analgesics are given for pain
;rostaglandin inhibitors )napro&en,ib"profen* are given for pain and
menorrhagia
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III. Hormonaltreatment
Indications:
!evere symptoms with small pelvis lesions
/ 8ec"rrence of symptoms after conservatives"rgery
3 9ay be given for a short time )C-/ wee$s*before s"rgery to ma$e dissection easier
0 After conservative s"rgery to allow anyresid"al lesion to regress
5 Hhen operation is contraindicated orref"sed by the patient
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. !se"do pregnancy
%v"lation and menstr"ation are inhibitedfor N months )C-D months* "sing acombined %
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#. !se"do menopa"se
Danaol: given orally 0-D mgday for C-N months Hea$ synthetic androgen !ide effects(
Androgenic effects( acne, male alopecia, hirs"tism, hoarseness ofvoice M hypertrophy of clitoris
/ 6ypo-oestrogenic effects( hot fl"shes, sweating, atrophy of
breasts, atrophic vaginitis, dry vagina, dyspare"nia M decreasedlibido
3 Anabolic effects( weight gain M edema
0 9etabolic effects( impaired gl"cose tolerance, increased ins"linre>"irements in diabetic cases, hepatic dysf"nction Bloodpress"re may be elevated
5
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#. !se"do menopa"se
4n2% -agonist: ?afarelin )synarel*( intranasally "sing a
nasal spray, / micrograms twice daily
Goserelin )4olade&*( 3C mg injected !