Ahmed Mukhtar Ali Consultant and Lecturer of Obstetrics and Gynecology, Faculty of MEDICINE, Zagazig University.

1. EndometriosisEndometriosis--AnAn
OverviewOverview
Presented by
Ahmed MukhtarAhmed Mukhtar

2. DefinitionDefinition
““Presence of endometrial tissue outsidePresence of endometrial tissue outside
the lining of the uterine cavitythe lining of the uterine cavity””
oror
““Proliferation of endometrium in anyProliferation of endometrium in any
site other than the uterine mucosasite other than the uterine mucosa””

3.  Age: common in reproductive periodAge: common in reproductive period
 True Incidence Unknown: ? 1-5% &True Incidence Unknown: ? 1-5% &
30 – 50 % infertility.30 – 50 % infertility.
 Does NOT Discriminate by Race.Does NOT Discriminate by Race.
 Histology: Endometrial Glands withHistology: Endometrial Glands with
Stroma +/- Inflammatory Reaction.Stroma +/- Inflammatory Reaction.
 Herdietary (Herdietary (↑↑ among sisters).↑↑ among sisters).

4. 1- Pelvic1- Pelvic
2-2- Extra pelvicExtra pelvic
 Umbilicus.Umbilicus.
 Scars (Lap.).Scars (Lap.).
 Lungs & plura.Lungs & plura.
 Others.Others.

5.  Uterine= Adenomyosis (50%).Uterine= Adenomyosis (50%).
 Extraut:Extraut:
- Ovary 30%- Ovary 30%
- Pelvic peritoneum 10%.- Pelvic peritoneum 10%.
- F. tube.- F. tube.
- Vagina.- Vagina.
-Bladder & rectum.-Bladder & rectum.
- Pelvic colon.- Pelvic colon.
- Ligaments.- Ligaments.

10.  Endometrial implantationEndometrial implantation
theorytheory
Retrograde
Vascular and lymphatic
Mechanical
 Immunological and geneticImmunological and genetic
theorytheory
 Composite theoryComposite theory

11. Theories OfTheories Of
HistiogenesisHistiogenesis
 In situ development
 Coelomic metaplasia theory
 Induction theory
 Embryonic cell nest
 Wolffian ducts
 Mullerian ducts
 Germinal epithelium of ovary
continue

12. Predisposing FactorsPredisposing Factors
1. Hyperoestrinism:1. Hyperoestrinism:
a)a) Fibroid & metropathiaFibroid & metropathia
hemorrhagica.hemorrhagica.
b)b) Delayed marriage, infertility.Delayed marriage, infertility.
c)c) Oestrogen secreting tumours of theOestrogen secreting tumours of the
ovary e.g. granulosa & theca cellovary e.g. granulosa & theca cell
tumours, or with prolonged oestrogentumours, or with prolonged oestrogen
therapy.therapy.
2. Cervical Stenosis.2. Cervical Stenosis.

13. Macroscopic appearanceMacroscopic appearance
1) Uterine endometriosis “Adenomyosis”:1) Uterine endometriosis “Adenomyosis”:
In both types:In both types:
C/S a whorled appearance.C/S a whorled appearance.
D.D:D.D: * No capsule.* No capsule.
* Dark brown spots.* Dark brown spots.
* M/E endometrial tissue.* M/E endometrial tissue.
a) Diffusea) Diffuse
(Common)(Common)
b) Localizedb) Localized
(occasional)(occasional)
* The uterus is* The uterus is
symmetricallysymmetrically
enlargedenlarged
* The uterus is* The uterus is
asymmetricalasymmetrical
enlargedenlarged
* Firm in* Firm in
consistencyconsistency
* Firm in* Firm in
consistencyconsistency

15. Macroscopic appearanceMacroscopic appearance
CONT….CONT….
2) Endometriosis of the2) Endometriosis of the
ovary:ovary:
- The ovary is enlarged and- The ovary is enlarged and
cystic.cystic.
- Surface burnt match head- Surface burnt match head
appearance.appearance.
- Tunica albuginea --->- Tunica albuginea --->

17.  Endometriosis is often misdiagnosedEndometriosis is often misdiagnosed
leading to delays in treatment sometimesleading to delays in treatment sometimes
for several years.for several years.
 Delay in diagnosis:Delay in diagnosis:
 Progression of symptoms.Progression of symptoms.
– Increasing infertility till completedIncreasing infertility till completed
reproductive failure.reproductive failure.

18. Symptoms (history).Symptoms (history).
Signs (Exam).Signs (Exam).
Investigations.Investigations.
DD.DD.
Cont…Cont…

19. AdenomyoAdenomyo
sissis
ExtraExtra
uterineuterine
endometriosendometrios
isis
AgeAge About 40About 40
yearsyears
About 30About 30
yearsyears
ParityParity MultiparaMultipara nulliparanullipara
SocioeconoSocioecono LowLow highhigh
Cont…Cont…

20. SymptomsSymptoms
 Asymptomatic.Asymptomatic.
 Pain (Pain (DYS…….):DYS…….):
- Dysmenorrhea (crescendo = progessive)- Dysmenorrhea (crescendo = progessive)
- Dyspareunia.- Dyspareunia.
- Dyschesia.- Dyschesia.
- Dysuria.- Dysuria.
 Backache.Backache.
 Acute abdomen.Acute abdomen.
 premenst. Tension syndrome.premenst. Tension syndrome.

21. SymptomsSymptoms contcont……
 Bleeding:Bleeding:
- Menorrhagia.- Menorrhagia.
- Cyclic hematuria during menstruation.- Cyclic hematuria during menstruation.
- Cyclic bleeding per rectum during- Cyclic bleeding per rectum during
menstruation.menstruation.
- Vicarious menstruation.- Vicarious menstruation.
 Infertility.Infertility.
 MassMass


22. Pelvic examination mayPelvic examination may
reveal:reveal:
1.1. Pelvic tenderness.Pelvic tenderness.
2.2. Fixed retroverted uterus.Fixed retroverted uterus.
3.3. Nodularity of the Douglas pouch andNodularity of the Douglas pouch and
uterosacral ligaments.uterosacral ligaments.
4. Ovaries4. Ovaries maymay bebe enlarged and tender .enlarged and tender .
Ovarian cyst mayOvarian cyst may bebe detected.detected.

23. 1. Laparoscopy .1. Laparoscopy .
2. Cystoscopy and proctosigmoidoscopy.2. Cystoscopy and proctosigmoidoscopy.
3. Histopathological examination3. Histopathological examination..
4. Imaging.4. Imaging.
5. Serum CA - 125.5. Serum CA - 125.
6. ? IL-8 & CEA.6. ? IL-8 & CEA.

24. LaparoscopyLaparoscopy
Value:Value:
It permits a “see and treat”It permits a “see and treat”
approach, although itsapproach, although its
effectiveness may be limited byeffectiveness may be limited by
the nature of the disease and thethe nature of the disease and the
surgeon's skill.surgeon's skill.

25. Appearance:Appearance:
Endometriosis May AppearEndometriosis May Appear
BrownBrown
Black (“Powderburn”)Black (“Powderburn”)
Clear (“Atypical”)Clear (“Atypical”)
Endometriosis May Be AssociatedEndometriosis May Be Associated
with Peritoneal Windowswith Peritoneal Windows
LaparoscopyLaparoscopy cont….

31. 1. Ovarian cysts.1. Ovarian cysts.
2. Pelvic inflammatory disease .2. Pelvic inflammatory disease .
3. Other causes of nodularity in Douglas3. Other causes of nodularity in Douglas
pouch as tuberculous peritoni­tis andpouch as tuberculous peritoni­tis and
metastases of ovarian cancer.metastases of ovarian cancer.
4. Causes of4. Causes of haematuriahaematuria ,, bleeding perbleeding per
rectumrectum andand acute abdominal painacute abdominal pain if theif the
patient is presented by one of thesepatient is presented by one of these
symptoms.symptoms.
5. Asymmetrical enlarged uterus.5. Asymmetrical enlarged uterus.

33. Ovarian EndometriosisOvarian Endometriosis
(Endometrioma)(Endometrioma)
Formed by invagination of theFormed by invagination of the
ovarian cortex after accumulationovarian cortex after accumulation
of menstrual debris from bleedingof menstrual debris from bleeding
of endometriotic implants.of endometriotic implants.

34. Rectovaginal SeptumRectovaginal Septum
EndometriosisEndometriosis
 Nodules are formed byNodules are formed by
hyperplasia of smooth muscleshyperplasia of smooth muscles
and fibrous tissue surroundingand fibrous tissue surrounding
the infiltrated tissue.the infiltrated tissue.
 No cyclical bleeding as theNo cyclical bleeding as the
endometriotic tissue are enclosedendometriotic tissue are enclosed
in nodules.in nodules.

35. Classification /Classification /
StagingStaging
 Several Proposed Schemes.
 Revised AFS System: Most Often
Used.
 Ranges from Stage I (Minimal) to
Stage IV (Severe).
 Staging Involves Location and Depth
of Disease, Extent of Adhesions.

37. Revised AFSRevised AFS
19851985
Stage I (minimal) 1 –
5.
Stage II (mild) 6 –
15.
Stage III (moderate) 16 –
40.
Stage IV (severe)

38. Treatment :Treatment :
ConsiderationConsideration
Age.Age.
Symptoms.Symptoms.
Stage.Stage.
Infertility.Infertility.

39. Treatment (RationaleTreatment (Rationale((
 Recognize Goals:Recognize Goals:
–– Pain ManagementPain Management
–– Preservation / Restoration of FertilityPreservation / Restoration of Fertility
 Discuss with Patient:Discuss with Patient:
–– Disease may be Chronic and Not CurableDisease may be Chronic and Not Curable
–– Optimal Treatment Unproven orOptimal Treatment Unproven or
NonexistentNonexistent

40. Endometriosis & IVFEndometriosis & IVF
 The presence of endometriosisThe presence of endometriosis
does not generally impair thedoes not generally impair the
results of IVF but it increases theresults of IVF but it increases the
risk of infection.risk of infection.
 It is preferable not to cauterizeIt is preferable not to cauterize
ovarian endometrioma if IVF or ICSIovarian endometrioma if IVF or ICSI
is indicated for fear of destructionis indicated for fear of destruction
of ovarian tissues.of ovarian tissues.

41. Expectant.Expectant.
Medical.Medical.
Hormonal.Hormonal.
Surgical.Surgical.

42. (I)(I)ExpectantExpectant
treatmenttreatment
 Young , asymptomatic infertileYoung , asymptomatic infertile
patient with mildpatient with mild
endometriosis.endometriosis.
 If pregnancy does notIf pregnancy does not
achieved within 12 - 18 monthsachieved within 12 - 18 months
of observation:of observation:
- hormonal or surgical treatment- hormonal or surgical treatment
is indicated .is indicated .

43. ))II) MedicalII) Medical
TreatmentTreatment
 Symptomatizing patients withSymptomatizing patients with
minimal or mild lesions:minimal or mild lesions:
1. Analgesics : for pain.1. Analgesics : for pain.
2. Prostaglandin inhibitors.2. Prostaglandin inhibitors.
3. Pregnancy.3. Pregnancy.
4. Opoids.4. Opoids.
5. NSAID.5. NSAID.

44. ))Ill) Hormonal treatmentIll) Hormonal treatment
Oestrogen.Oestrogen.
Combined oestrogen-Combined oestrogen-
progestogen Pills.progestogen Pills.
Progestins.Progestins.
Danazol.Danazol.
GnRH agonists.GnRH agonists.

45. Indications of HormonalIndications of Hormonal
tttttt
1. Small endometriotic; lesions.1. Small endometriotic; lesions.
2. Recurrence after conservative2. Recurrence after conservative
surgery.surgery.
3. Preoperative for 6-12 weeks to3. Preoperative for 6-12 weeks to
decrease size.decrease size.
4. Postoperative for residual4. Postoperative for residual
lesions.lesions.
5. When operation is5. When operation is
contraindicated or refused by thecontraindicated or refused by the
patient.patient.

46. Aim of the hormonalAim of the hormonal
therapytherapy
)A) Pseudopregnancy :)A) Pseudopregnancy :
1.1. Combined low - dose contraceptive pills)6 - 18Combined low - dose contraceptive pills)6 - 18
months to inhibit ovulation and menstruationmonths to inhibit ovulation and menstruation
and induce decidualization to endometrioticand induce decidualization to endometriotic
tissues).tissues).
oror
2.2. Progestins )to avoid oestrogen's side effectsProgestins )to avoid oestrogen's side effects
medroxy progesterone acetate Depo medroxymedroxy progesterone acetate Depo medroxy
progesterone acetate )DMPA) can be given inprogesterone acetate )DMPA) can be given in
a dose of 150 mg IM every I - 3 months .a dose of 150 mg IM every I - 3 months .

47. Aim of the hormonalAim of the hormonal
therapytherapy contcont….….
(B)(B) PseudomenopausePseudomenopause
(induction of amenorrhoea)(induction of amenorrhoea)
by:by:
1. Danazol.1. Danazol.
2. Gn RH analogues.2. Gn RH analogues.
3. Gestrinone.3. Gestrinone.
4. Gossypol.4. Gossypol.

48. DanazolDanazol
 Weak Androgen (isoxazole derivativeWeak Androgen (isoxazole derivative
of 16 – alpha ethinyl testosterone).of 16 – alpha ethinyl testosterone).
 Suppresses LH / FSH.Suppresses LH / FSH.
 Causes Endometrial Regression,Causes Endometrial Regression,
Atrophy.Atrophy.
 Expensive.Expensive.
 Dose 400 – 800 mgm orally /day/ 6 –Dose 400 – 800 mgm orally /day/ 6 –
9 months.9 months.
 Side-Effects: Weight Gain,Side-Effects: Weight Gain,
Masculinization, Occ. PermanentMasculinization, Occ. Permanent

49. GnRH-aGnRH-a
 Initially Stimulate FSH / LHInitially Stimulate FSH / LH
Release.Release.
 Down-Regulates GnRHDown-Regulates GnRH
Receptors–”Pseudomenopause”.Receptors–”Pseudomenopause”.
 Long-Term Success Varies.Long-Term Success Varies.
 Expensive.Expensive.
 Use Limited by HypoestrogenicUse Limited by Hypoestrogenic
Effects.Effects.
 May be Combined with Add-Back (?May be Combined with Add-Back (?
>1 Year ), using E2/progesterone>1 Year ), using E2/progesterone

50. GnRH-aGnRH-a
AddbackAddback ((E2/progesteroneE2/progesterone
preparation(preparation( ::
Reduce effect on boneReduce effect on bone
mineral density.mineral density.
Relieve hot flushes.Relieve hot flushes.

51. GossypolGossypol
 Is a phenolic compound extractedIs a phenolic compound extracted
from the seed , stem and root of thefrom the seed , stem and root of the
cotton plant.cotton plant.
 It is a sup­pressor of FSH and LH ,It is a sup­pressor of FSH and LH ,
producing endomelrial atrophy inproducing endomelrial atrophy in
about 50% of patients after 3 monthsabout 50% of patients after 3 months
..
 Dose : 20 mg daily for 2 months thenDose : 20 mg daily for 2 months then
25 mg twice weekly for main­tenance25 mg twice weekly for main­tenance
..

52. GestrinoneGestrinone
 It is a synthetic 19 Nor steroid exhibitsIt is a synthetic 19 Nor steroid exhibits
marked and - progcs-terogenic and anti -marked and - progcs-terogenic and anti -
oestrogenic as well as mild androgenicoestrogenic as well as mild androgenic
and anti -gonadotrophic properties .and anti -gonadotrophic properties .
 The endocrine effects of Gestrinone areThe endocrine effects of Gestrinone are
similar to those of Danazol which leadssimilar to those of Danazol which leads
mainly to inhibition of ovari­anmainly to inhibition of ovari­an
steroidogenesis .steroidogenesis .
 The dose is 2.5 - 5 mg orally twiceThe dose is 2.5 - 5 mg orally twice
weekly .weekly .

53. (Laparoscopy /(Laparoscopy /
LaparotomyLaparotomy((

ExcisionExcision sísí / Fulgeration/ Fulgeration no!no!
 Resection of Endometrioma.Resection of Endometrioma.
 Lysis of Adhesions, Cul-de-sacLysis of Adhesions, Cul-de-sac
Reconstruction.Reconstruction.
 Uterosacral Nerve Ablation.Uterosacral Nerve Ablation.
 Presacral Neurectomy.Presacral Neurectomy.
 Appendectomy.Appendectomy.
 Uterine Suspension (? Efficacy).Uterine Suspension (? Efficacy).
 Hysterectomy +/- BSO.Hysterectomy +/- BSO.

55. IssuesIssues
 ? Removal of Ovaries at? Removal of Ovaries at
HysterectomyHysterectomy
 ? Need for Progestins if ERT? Need for Progestins if ERT
GivenGiven
 ? Adjuvant Treatment? Adjuvant Treatment
PostoperativelyPostoperatively
 ? Lupron Challenge Test for? Lupron Challenge Test for
DiagnosisDiagnosis


56. Conservative surgeryConservative surgery
1. Large adnexal masses .1. Large adnexal masses .
2. Failure of medical and2. Failure of medical and
hormonal treatment.hormonal treatment.
3. Severe endometriosis3. Severe endometriosis
(follow principles of(follow principles of
microsurgery).microsurgery).

57. The Principles ofThe Principles of
MicrosurgicalMicrosurgical
TechniqueTechnique
1. The use of magnification by1. The use of magnification by
microscope or head loupes.microscope or head loupes.
2. gentle handling of tissues.2. gentle handling of tissues.
3. meticulous tissues dissection.3. meticulous tissues dissection.
4. precise haemostasis.4. precise haemostasis.
5. careful approximation of tissues.5. careful approximation of tissues.

58. The Principles of MicrosurgicalThe Principles of Microsurgical
TechniqueTechnique contcont……
6. Irrigation of the field with heparined6. Irrigation of the field with heparined
Ringer's lactate.Ringer's lactate.
7. The use of non - or delayed7. The use of non - or delayed
absorbable suture material , cut gutabsorbable suture material , cut gut
should be avoided as it is irritant toshould be avoided as it is irritant to
the tissue.the tissue.
8. Contamination of the pelvis with8. Contamination of the pelvis with
foreign material as talc powder fromforeign material as talc powder from
gloves should be avoided as itgloves should be avoided as it
provokes inflammation .provokes inflammation .
9. Intra - operative dextran 70.9. Intra - operative dextran 70.

59. ConclusionConclusion
 Endometriosis is a mystery tour asEndometriosis is a mystery tour as
it requires decision making at everyit requires decision making at every
stage by the physician and thestage by the physician and the
patient.patient.
 Endometriosis still stand as one ofEndometriosis still stand as one of
the most-investigated disorders inthe most-investigated disorders in
gynecology.gynecology. SOSO is one of theis one of the
highest priorities for research.highest priorities for research.

60. AdenomyosisAdenomyosis

61. DefinitionDefinition：：
A benign uterine condition in whichA benign uterine condition in which
endometrial glands and stroma areendometrial glands and stroma are
found deep in the myometrium.found deep in the myometrium.

62. EtiologyEtiology：：
 Basal endometrial hyperplasiaBasal endometrial hyperplasia invading ainvading a
hyperplastic myometrial stromahyperplastic myometrial stroma..
 Four primary theoriesFour primary theories ：：
HeredityHeredity
TraumaTrauma
HyperestrogenemiaHyperestrogenemia
Viral transmissionViral transmission

63. PathologyPathology
—— grossgross
appearanceappearance：： Usually hyperemic withUsually hyperemic with thickenedthickened
wallswalls
 The foci are frequentlyThe foci are frequently scatteredscattered
diffuselydiffusely throughout the myometrium.throughout the myometrium.
 OccasionallyOccasionally ，， may be moremay be more
circumscribedcircumscribed ，， with the formation ofwith the formation of
a distinct nodulea distinct nodule ，， anan
adenomyomaadenomyoma..

64. The thickened and spongy appearingThe thickened and spongy appearing
myometrial wall of this sectioned uterus is typicalmyometrial wall of this sectioned uterus is typical
of adenomyosis. There is also a small whiteof adenomyosis. There is also a small white
leiomyoma at the lower left.leiomyoma at the lower left.

65. ClinicalClinical
featuresfeatures （（ 11 ）：）：
 Symptomatic adenomyosis occursSymptomatic adenomyosis occurs
primarily in parous women over the ageprimarily in parous women over the age
of 40 .of 40 .
（（ 3030 ～～ 5050 ））
 Classic symptomsClassic symptoms ：：
secondary dysmenorrheasecondary dysmenorrhea
abnormal uterine bleedingabnormal uterine bleeding

66. ClinicalClinical
featuresfeatures （（ 22）：）：
 Most common physical signMost common physical sign ：：
aa diffuselydiffusely enlargedenlarged uterusuterus ，，
(rarely exceeds 12 weeks’ gestation in size)(rarely exceeds 12 weeks’ gestation in size)
particularly tender duringparticularly tender during
menstruationmenstruation

67. DiagnosisDiagnosis：：
 HistoryHistory
 Pelvic examinationsPelvic examinations
 UltrasonographyUltrasonography
 Serum markersSerum markers ：： CA-125CA-125↑↑

68. TreatmentTreatment：：
 Hormone therapyHormone therapy
 HysterectomyHysterectomy ，， the only uniformlythe only uniformly
successful treatment forsuccessful treatment for
adenomyosisadenomyosis ，， is necessary.is necessary.