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1. Endometriosis

2. Definition.
Endometriosis is the presence of functioning
endometrial glands and stroma outside their
usual location in the uterine cavity, often
resulting in significant pelvic adhesions with or
without associated inflammatory cells or
hemosiderin-laden macrophages.

3. It is primarily a pelvic disease with implants
on, or adhesions of, the ovaries, fallopian tubes,
uterosacral ligaments, rectosigmoid, and
bladder. Less commonly, endometriosis can be
found outside the pelvis, suggesting a
metastatic spread. Endometriosis is general a
benign disease that usually affects women in
their reproductive years. There have been,
however, several cases in the recent literature
of endometrioid carcinoma arising within
endometriosis

4. Endometriosis is often associated with:
 Crippling dysmenorrhea
 Severe dyspareunia
 Chronic pelvic pain
 Infertility

5. Infertiliy.
Pregnancy, with its positive effect on
improving endometriosis, often is very difficult
to achieve.
 Infertility among women with endometriosis is
approximately 30% to 40%.
 Endometriosis in infertile women has been
demonstrated by laparoscopy in 15% to 25% of
cases.

6.  Retrograde menstrual flow
 Hematogenous or lymphatic spread.
 Metaplasia of coelomic epithelium.
 Genetic and immunologic influences

7. Retrograde menstrual flow.
One theory postulates that the backward flow of
menstrual debris through the fallopian tubes
causes the endometrial cells to spread into the
pelvis. These cells implant there or set up
irritative foci, which stimulate coelomic
metaplasia and differentiation of the peritoneal
cells into endometrial-type tissue.
 Clinical evidence. Endometriosis is commonly
found in dependent portions of the pelvis, most
frequently on the ovaries, cul-de-sac, and
uterosacral ligament. Flow of menstrual blood
from the fallopian tubes has been observed
during laparoscopy.
 Experimental evidence. Endometrial fragments
from the menstrual flow can grow both in tissue
culture and after injection beneath the skin of the
abdominal wall.

8. Hematogenous or lymphatic spread.
Endometriosis at sites distant from the pelvis may
be causedbye vascular or lymphatic transport of
endometrial fragments. This could explain the
presence of endometriosis at distant sites s...uch as
brain and lungs.
Metaplasia of coelomic epithelium.
The transformation of coelomic epithelium results
from some as yet unspecified stimuli.
Endometriosis has been reported in a prepubertal
girl, and in many adolescents who have had very
few menstrual cycles.

9. Genetic and immunologic influences.
The relative risk of endometriosis is 7% in siblings,
compared to 1% in a control group. In addition, an
immonulogic deficiency may be involved in the
pathogenesis of endometriosis. Monkeys with
spontaneous endometriosis were found to have a
cell-mediated response to autologous endometrial
tissue that was significantly lower than that of
control animals. Thus, a genetic influence could
manifest itself through a deficient immunologic
system.

10. DIAGNOSIS
 Signs and symptoms. Endometriosis should be suspected in any
woman complaining of infertility. Suspicion is heightened when
she also complains of dysmenorrhea and dyspareunia.
 Dysmenorrhea. Painful menses are suggestive of endometriosis if
they begin after years of relatively pain-free menses. With the
increased use of laparoscopy, many adolescents with primary
dysmenorrhea are being diagnosed with endometriosis.
 Pelvic pain. Pain can be diffuse in the pelvis, or it can be more
localized, often in the area of the rectum. The degree of
endometriosis often does not correlate with the amount of pain
experienced. Many women who have endometriosis are
asymptomatic.
 Dyspareunia. Painful intercourse may be caused by:
 Endometrial implants of the uterosacral ligaments
 Endometriomas of the ovaries
 Fixed retroversion of the uterus secondary to the endometriosis

11. Infertility.
 When endometriosis involves the ovaries and causes
adhesions, there is no question of its role in causing
infertility. The association between minimal
endometriosis and infertility is less well documented.
Medical therapy in these cases does not improve
fertility. Significant quantities of prostaglandin,
reported to be secreted from the endometrial implants
near the tubes and ovaries, may:
 Interfere with tubal function and mobility, ovulation,
steroidogenesis, and luteal function
 Contribute to the luteinized unruptured follicle
syndrome, in which the ovum is trapped within the
follicle and not releases with the luteinizing hormone
surge

12. Other signs of e endometriosis.
Irregular menses, cyclic rectal bleeding or pain,
and hematuria may be signs of endometriosis
of the ovaries, rectosigmoid, and bladder,
respectively.

13.  Examination.The diagnosis of endometriosis
cmbines the findings from the history, pelvic
examination, and laparoscopy. The only way to
diagnose endometriosis is by visualization at
surgery and laparoscopy or by biopsy of an
implant; history and physical examination are
suggestive, but not diagnostic.
 History. The symptoms described by the patient
are correlated with the physical examination and
the diagnostic procedures in arriving at a
diagnosis. A history of endometriosis in the
patient’s mother of sisters is important.

14.  Pelvic examination. With minimal endometriosis,
the pelvic examination may provide only normal
findings.
 Beading, nodularity, and tenderness of the
uterosacral ligaments are characteristic of
endometriosis are can be best appreciated on
rectovaginal examination.
 Endometriomas, or chocolate cysts of the ovaries,
are palpated as adnexal masses, often fixed to the
lateral pelvic walls or posterior to the broad
ligament.
 The uterus is often in a fixed, retroverted position.

15.  The CA-125(canser antigen) assay tests for a cell
surface antigen found on derivatives of the
coelomic epithelium, which includes the
endometrium.
 Serum levels are elevated in patients with
endometriosis.
 The assay correlates with the degree of disease and
response to treatment.
 It can be used as a marker for the recurrence of
endometriosis.

16. Laparoscopy. Visual diagnosis of
endometriosis with the laparoscope is essential
because ovarian enlargement and nodularity of
the cul-de-sac may result from metastatic
ovarian carcinoma, bowel cancer, or calcified
mesotheliomas.

17. Classification of endometriosis.
Because both treatment and prognosis of endometriosis
are determined, to some extant, by the severity of the
disease, it would be desirable to have a uniform system
of classification that takes into account both the extant
and severity of the disease. Unfortunately, the diversity
of the different classification systems precludes
accurate comparisons, and questions regarding the
most efficacious treatment of varying degrees of
endometriosis go unanswered. The most commonly
used classification system, developed by the American
Fertility Society, is based on findings from laparoscopy
or laparotomy.

18. MANAGEMENT.
The age of the patient, the extant of the
disease, the reproductive plans of the couple,
the duration of the infertility, and the severity
of symptoms are all important considerations.

19.  Expectant therapy.No therapy has proven to be a
logical approach to patients with minimal disease.
This situation is especially relevant to the young
woman with short-term infertility. In a
comparison of patients with mild endometriosis,
the pregnancy rate in 1 years was 72% in patients
managed with an expectant approach and 76% in
patients treated with conservative surgery.
 Medical therapy. Ectopic endometrium responds
to cyclic hormone secretion in a fashion similar to
normal endometrium; thus, hormonal
suppression of woman’s menses constitutes the
basis of medical therapy

20. Oral contraceptives.
The use of a continuous combination estrogen
with progestin pill creates a pseudopregnancy
with amenorrhea. The pseudopregnancy causes a
deciduation, necrobiosis, and resorption of the
ectopic endometrium. This form of treatment is
appropriate only in mild endometriosis that does
not involve much distortion of the pelvic anatomy
by adhesions or endometriomas. An oral
contraceptive with strong progestational
properties should be taken continuously for 9
months in the following manner.

21.  Dosage.The pills are given daily on a continuous
basis. Breakthrough bleeding can be controlled by
adding conjugated estrogens for short periods. The
therapy is continued for 6 to 12 months.
 The pregnancy rate after pseudopregnancy has
generally been between 25% and 50%.
 Recurrence rate. The fact that
pseudopregnancydoesn not cure endometriosis is
reflected in the recurrence rate of the disease –
about 17% to 18% in 1 year, and higher with
extended periods of posttreatment observation.

22.  Danazol.Danazol, commonly used in the past, is
being replaced by the gonadotropin-releasing
hormone (GnFH) agonists. Danazol creates a high-
androgen, low-estrogen environment.
 Dosage. The effective dose is 400 to 800 mg/day
(200-mg tablets) for 6 months.
 Lower doses often mainly symptomatic relief.
 Higher doses. The pregnancy rate when the higher
doses are used to 40% to 60% after 6 months of
pseudomenopause.
 Side effects are related both to the hypoestrogenic
environment that danazol creates and to its
androgenic properties.

23.  Hypoestrogenic properties include water
retention, decreased breast size, atrophic vaginitis,
dyspareunia, hot flashes, muscle cramps, and
emotional lability.
 Androgenic properties include weight gain, acne,
oily skin, deepening of the voice, and growth of
facial hair.
 Prognosis with danazolis related to the extent of
the endometriosis and the dose of the drug; with a
regimen of 800 mg/day for 4 to 9 months, the
pregnancy rate is approximately 60%.
 Recurrence rates are highest (23%) during the first
year after stopping the danazol treatment.

24.  Progestogens.Long-acting, intramuscular
progestogens (medroxyprogesterone acetate
100-200 mg/month) suppress hypothalamic-
pituitary function, leading to amenorrhea and
decidual, rather than atrophic, endometrial
changes.
 Breakthrough bleeding is a nuisance side
effect, but weight gain and depression are
potential problems for the patient.
 Prolonged amenorrhea after treatment makes
this regimen undesirable in women who want
immediate fertility.

25.  GnRH agonists. With continuous administration, these
agents first stimulate gonadotropin release, then
suppress pituitary – ovarian function, leading to a
“medical hypophysectomy”.
 Administration. The drug is administered either daily
in the form of intranasal spray or subcutaneous
injection or monthly in a depot injection.
 Effects. Amenorrhea and atrophic endometrial changes
occur.
 Menopausal-type symptoms (e.g. hot flashes,
decreases libido, and vaginal dryness) occur because of
the hypoestrogenic state.
 Prolonged use can result in significant bone loss
leading to osteoporosis.

26. Surgical therapy.
If there are anatomic factors such as tuboovarian
adhesions or large endometriomas indicative of
moderate to severe disease, the treatment of
choice is surgery. Medical therapy and
hormone suppression do not dissolve the
adhesions or eliminate the endometriomas. The
success of surgery in relieving infertility is
directly related to the severity of the
endometriosis.

27. Conservative surgery involves the excision,
fulguration, or laser vaporization of
endometriotic tissue, the excision of ovarian
endometriomas, and the resection of severely
involved pelvic viscera, leaving the uterus and
at least one tube and ovary intact. Additional
infertility surgery measures for endometriosis
include the gentle handling of tissue, lysis of
adhesions, precise dissection, and meticulous
hemostasis.

28.  Reconstruction of all peritoneal surfaces is essential.
The raw areas in the pelvis can be covered with free
peritoneal or omental grafts to prevent adhesions.
 Postoperative use of hormones has been the subject of
great controversy because the highest pregnancy rates
occur in the first year after conservative surgery; thus,
most physicians are reluctant to use hormones that
prevent pregnancy, even for a few months. If
pregnancy does not occur within 2 years of surgery for
endometriosis, the long-term prognosis is poor.

29.  Radical surgery, which involves a total abdominal
hysterectomy and bilateral salpingo-oophorectomy, is
used in patients whose childbearing is finished or in
those whose endometriosis is so severe that it
precludes any attempt at reconstruction. A less than
complete pelvic cleanout in these patients guarantees
reoperation at a later date. Radical surgery for
endometriosis in women in their reproductive years
means castration at an early age. In these women,
replacement estrogen is essential to prevent problems
with loss of calcium from bones, atrophic changes in
the pelvis, especially the vagina, and premature aging
of the cardiovascular system. Estrogen replacement
therapy carries only a small risk of inciting growth of
residual endometriosis.

30. MAINTENANCE OF FERTILITY AND
SYMPTOMATIC RELIEF. Finding
endometriosis (by laparoscopy) in a young
woman who has pelvic pain and no immediate
interest in pregnancy is a common occurrence.
The goals for this type of patient are relief of
the dysmenorrhea and prevention of further
growth of the endometriosis.

31.  Birth control pills. Cyclic birth control pills are
appropriate treatment for mild disease because they
reduce the amount endometrial buildup and shedding,
thereby preventing further growth of the
endometriosis.
 Nonsteroidal antinflammatory drugs (NSAIDs).
Women with endometriosis show increased
concentrations of prostaglandins in the peritoneal
fluid. The prostaglandin synthetase inhibitors (i.g.,
NASAIDs) are effective in controlling the
endometriosis-related dysmenorrhea.
 Birth control pills and NASAIDs. The two may be
administered simultaneously if neither one
individually controls the dysmenorrhea.