Endometriosis

ENDOMETRIOSIS

 Is characterized by the presence of

endometrial tissue on the ovaries, fallopia
n tubes or other sites, causing pain or infe
rtility.
The disease tends to progress under the
repetitive influence of the menstrual cycle I

 Dense adhesions are commonly associated with advanced

endometriosis.
They can be treated with laparoscopy techniques, but are more likely to
reform after surgery.

 Minimal adhesions between the left ovary and pelvic

sidewall.
Commonly associated with mild to moderate endometriosis.

Ovary with endometrioma.

 This picture shows a chocolate cyst, which can be quite

common in more advanced endometriosis

Rupture endometrioma

Endometriosis!
Epidemiology
> 70 million women and girls have
Endometriosis world-wide.
10 - 20 % of women of reproductive age have
Endometriosis.
It is more common than breast cancer or Aids,
and many other diseases, that are well known

Endometriosis is not usually fatal

 the longer that this disease

goes undiagnosed
the more damage it can do.

Pathogenesis
is not well understood
is probably multifactorial
in origin
the most widely
embraced theory
involves retrograde
menstruation5

Retrograde menstruation

Investigation
A definitive diagnosis can be made only by
means of laparoscopy
Imaging tests: ultrasound, MRI, CT, are

occasionally used to identify individual

lesions

Biochemical markers
CA-125 A recent study of this antigen level,
showed it to be high in 90 percent of women
with Endometriosis

Stages of Endometriosis
Based on the severity, location,
amount, depth and size of growths.
The stages of the disease do not
indicate the level of pain, infertility or
symptoms.
the correlation between stage and
extent of disease remains controversial

Stages of Endometriosis
Stage 1 - minimal disease, superficial
and filmy adhesions
Stage 2 - mild disease, superficial and
deep endometriosis
Stage 3 - moderate disease, deep
endometriosis and adhesions
Stage 4 - severe disease, deep
endometriosis, dense adhesion

Classification of Endometriosis
(Modified American Fertility
Society
System)
Base on extent of

peritoneum,ovary,tube,cul de sac
endometriosis and adhesions
Stage I Score 1-5
minimal
Stage II Score 6-15
mild
Stage III Score 16-40
moderate
Stage IV Score > 40
Severe

Classification of Endometriosis

Ovar Adhesio < 1/3

y

ns
R
Filmy
Dense
L Filmy

Dense
Tube R

1/3-2/3

enclosure enclosure
1
2

>2/3encl
osure
4

16

1
4

2
8

4
16

Classification of Endometriosis

Periton Endometriosis <

eum

Ovary

Superficial
Deep

1CM
1
2

R Superficial
Deep
L Superficial
Deep
posterior cul

1
4
1
4
partial

1-3 cm

>3cm

2
4

4
6

2
16
2
16

4
20
4
20

Common site of endometriosis

Endometriosis Symptoms
Endometriosis does
not follow any
distinct pattern
The symptoms of
Endometriosis vary
from one woman to
another
The most common
symptom is pelvic
pain.

The most common symptoms

Pain before and during periods

Pain with intercourse
General, chronic pelvic pain throughout the month
Heavy and/or irregular periods
Painful urination during menstruation
Infertility
Fatigue
Low back pain
Painful bowel movements, especially during
menstruation
Diarrhoea or constipation

Symptoms relate to endometriosis site

Reproductive Endometriosis
Pelvic pain

Ectopic (tubal) pregnancy

Dysmenorrhea
Infertility
Miscarriage(s)
Painful ovulation

Uterosacral/Presacral Nerve Endometriosis

Backache
Leg pain
Dyspareunia

Cul-de-sac ("Pouch of Douglas") Endometriosis

Dyspareunia (pain during intercourse)
Gastrointestinal symptoms
Pain after intercourse

Symptoms relate to endometriosis site

Gastrointestinal symptoms of Endometriosis

Nausea
Diarrhea
Blood in stool
Bloating
Vomiting
Rectal pain
Rectal bleeding
Tailbone pain
Abdominal cramping
Constipation
Sharp gas pains
Painful bowel movements

Symptoms relate to endometriosis site

Urinary tract Endometriosis
Blood in urine
Painful or burning urination
Hypertension
Tenderness around the kidneys
Flank pain radiating toward the groin
Urinary frequency, retention, or urgency

Symptoms relate to endometriosis site

Pleural (lung & chest cavity) Endometriosis
Very occasionally
Coughing up of blood or bloody sputum, particularly
coinciding with menses
Accumulation of air or gas in the chest cavity
Constricting chest pain and/or shoulder pain
Collection of blood and/or pulmonary nodule in chest
cavity (revealed under testing)
Shortness of breath

Symptoms relate to endometriosis site

Skin Endometriosis
Painful nodules, often visible to the naked
eye, at the skin's surface. Can bleed during
menses and/or appear blue upon
inspection.

Sciatic Endometriosis
Hip pain

pain that radiates from the buttock and

down the leg

Differential diagnosis by symptoms

Generalized pelvic pain
Pelvic inflammatory disease
Endometritis
Sexual or physical abuse
Neoplasms, benign or malignant
Ovarian torsion
Pelvic adhesion
Nongynecologic causes

Differential diagnosis by symptoms

Dysmenorrhea
Primary
Secondary (adenomyosis, myomas,
infection, cervical stenosis)

Differential diagnosis by symptoms

Dyspareunia
Musculoskeletal causes (pelvic relaxation,
levator spasm)
Gastrointestinal tract (constipation,
irritable bowel syndrome)
Urinary tract (urethral syndrome,
interstitial cystitis)
Infection
Pelvic vascular congestion

Differential diagnosis by symptoms

Infertility
Male factor
Tubal disease (infection)
Anovulation
Cervical factors (mucus, sperm antibodies,
stenosis)
Luteal phase deficiency

Treatment options for Endometriosis

There are general points which should be taken into
consideration
The severity of the symptoms
The type of symptoms
The age of the patient
The desire to get pregnant or not
Length of treatment
Coping with side-effects of drug treatment
Cost

Treatment options
Observation with no medical
intervention
Hormone treatment
Surgery
Combined treatment

Drugs Commonly used

GnRH agonists
inhibit the secretion of gonadotropin a complete block of egg
development, estrogen production and menstrual cycle, makes
'menopausal'
Danazol
is a mild form of the male hormone testosterone inhibits
leuteinizing hormone (LH) and follicle-stimulating hormone (FSH
)
Gestrinone
It works in much the same way as danazol with similar, but
milder, side effects
Contraceptive pill
suppress LH and FSH and prevent ovulation
Progestational Agents
Depo-Provera
Progesterone hormone tablets
The Mirena Coil (IUD with Levonorgestrel )

GnRH agonists
Gonadotropin-releasing hormone agonist
leuprolide (Lupron, Eligard)
buserelin (Suprefact, Suprecor)
nafarelin (Synarel)
histrelin (Supprelin)
goserelin (Zoladex)
deslorelin (Suprelorin, Ovuplant)

GnRH antagonist
Abarelix (Plenaxis)
Cetrorelix (Cetrotide), by Serono
Ganirelix (Antagon), by Organon
International

Surgery
Definitive surgery, which includes
hysterectomy and oophorectomy, is reserv
ed for use in women with intractable pain
who no longer desire pregnancy.
In less severe cases, one ovary may be
retained to preserve ovarian function

Surgical treatment

Surgical Treatment

Laparoscopic excision of nodular

endometrial lesions overlying the rectu
m

Nodular endometrial lesions in the

posterior cul-de-sac.

Surgical vs. Medical Treatment of

Endometriosis
Treatm
ent

Advantages

Treatment
Surgical

Disadvantages

Expensive

Possibly better long-term results

Invasive

Definitive diagnosis

Disadvantages

Beneficial for infertility

Expensive
Invasive
Possibly better long-term
results
Definitive diagnosis
Option for definitive treatment

Beneficial for infertility

Surgical

Advantages

Option for definitive treatment

Medical

Medical

Decreased initial cost

Empiric treatment
Effective for pain relief

Decreased initial cost

Adverse effects
common

Empiric treatment

Unlikely to improve
fertility

Effective for pain relief

Adverse effects common

Unlikely to improve fertility

Recurrence Rates
a laparoscopically defined cumulative five-year
recurrence rate of about 19 percent.
the long-term benefit of surgical intervention for
pain is enhanced by definitive surgery, including
bilateral oophorectomy, with a 10 percent cumul
ative recurrence after 10 years.
surgical treatment is the apparently lower
recurrence rate compared with medical treatmen
t