Definition Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis. It is a benign but it is locally invasive. Prevalence The real one is due to delayed marriage, postponement of first conception and adoption of small family norm. The apparent one is due to increased use of diagnostic laparoscopy as well as hightened awareness of this disease complex amongst the gynecologists Sites Abdominal: Usually confined to the abdominal structures below the level of umbilicus. Extra-abdominal: Common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix. Remote Pathology Naked Eye Appearance: The appearance of the lesion depends on the organs involved, extent of lesion and reaction of the surrounding tissues. Pelvic endometriosis: Small black dots, called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas. Fibrosis and scarring Symptoms Dysmenorrhea (70%) Abnormal menstruation (20%) Infertility (40–60%) Dyspareunia (20–40%) Chronic Pelvic Pain Abdominal Pain Urinary— frequency, dysuria, back pain or even hematuria. Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena. Chronic fatigue, perimenstrual symptoms (bowel, bladder). Hemoptysis (rarely), chest pain. Surgical scars—cyclical pain and bleeding. Examination Abdominal palpation A mass may be felt in the lower abdomen arising from the enlarged tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility. Pelvic Examination Pelvic tenderness, nodules in the pouch of Douglas, nodular feel of the uterosacral ligaments, fixed uterus or unilateral or bilateral adnexal mass of varying sizes Diagnosis Bichemical parameters: Serum CA 125 Monocyte Chemotactic Protein (MCP-1) Imaging: TVS - ovarian endometriomas Endorectal USG - Rectosigmoid endometriosis MRI - deep infiltrating endometriosis. Colonoscopy, rectosigmoidoscopy and cystoscopy Differential Diagnosis Chronic pelvic infection / symptomatic endometriosis. Laparoscopy is helpful in actual diagnosis. Ovarian endometrioma / benign ovarian tumor / malignant ovarian. Ultrasonography or Laparoscopy Rupture of the chocolate cyst / torsion or rupture of the ovarian tumour, disturbed ectopic pregnancy, appendicitis or diverticulitis. Complications Endocrinopathy Rupture of chocolate cyst Infection of chocolate cyst Obstructive features: Intestinal obstruction Ureteral obstruction → hydroureter hydronephrosis → renal infection Endocrinopathy in Endometriosis Corpus luteum insufficiency Luteolysis due to ↑ PGF. ™Luteinized unruptured follicle (LUF) Anovulation ™Elevated prolactin level Double LH peak. Staging Endometrios is should be staged appropriately. To predict prognosis. To choose therapy. To evaluate the treatment protocol. The stage is determined by adding specific points given to each.

1. ENDOMETRIOSIS
Dr. Yashika

2. Definition
 Presence of functioning endometrium
(glands and stroma) in sites other than
uterine mucosa is called endometriosis.
 It is a benign but it is locally invasive.

3. Prevalence
 The real one is due to delayed marriage,
postponement of first conception and adoption
of small family norm.
 The apparent one is due to increased use of
diagnostic laparoscopy as well as hightened
awareness of this disease complex amongst
the gynecologists

4. Sites
 Abdominal: Usually confined to the
abdominal structures below the level of
umbilicus.
 Extra-abdominal: Common sites are
abdominal scar of hysterotomy, cesarean
section, tubectomy and myomectomy,
umbilicus, episiotomy scar, vagina and cervix.
 Remote

5. Pathology
 Naked Eye Appearance: The appearance of
the lesion depends on the organs involved,
extent of lesion and reaction of the surrounding
tissues.
 Pelvic endometriosis: Small black dots, called
‘powder burns’ seen on the uterosacral
ligaments and pouch of Douglas.
 Fibrosis and scarring

7. Symptoms
 Dysmenorrhea (70%)
 Abnormal menstruation (20%)
 Infertility (40–60%)
 Dyspareunia (20–40%)
 Chronic Pelvic Pain
 Abdominal Pain

8.  Urinary— frequency, dysuria, back pain or even
hematuria.
 Sigmoid colon and rectum—painful defecation
(dyschezia), diarrhea, constipation, rectal bleeding or
even melena.
 Chronic fatigue, perimenstrual symptoms (bowel,
bladder).
 Hemoptysis (rarely), chest pain.
 Surgical scars—cyclical pain and bleeding.

9. Examination
Abdominal palpation
 A mass may be felt in the lower abdomen arising from the
enlarged tubo-ovarian mass due to endometriotic
adhesions. The mass is tender with restricted mobility.
Pelvic Examination
 Pelvic tenderness, nodules in the pouch of Douglas,
nodular feel of the uterosacral ligaments, fixed uterus or
unilateral or bilateral adnexal mass of varying sizes

10. Diagnosis
Bichemical parameters:
 Serum CA 125
 Monocyte Chemotactic Protein (MCP-1)
Imaging:
TVS - ovarian endometriomas
Endorectal USG - Rectosigmoid endometriosis
MRI - deep infiltrating endometriosis.
Colonoscopy, rectosigmoidoscopy and cystoscopy

11. Differential Diagnosis
 Chronic pelvic infection / symptomatic endometriosis.
Laparoscopy is helpful in actual diagnosis.
 Ovarian endometrioma / benign ovarian tumor /
malignant ovarian.
Ultrasonography or Laparoscopy
 Rupture of the chocolate cyst / torsion or rupture of the
ovarian tumour, disturbed ectopic pregnancy,
appendicitis or diverticulitis.

12. Complications
 Endocrinopathy
 Rupture of chocolate cyst
 Infection of chocolate cyst
Obstructive features:
 Intestinal obstruction
 Ureteral obstruction → hydroureter
 hydronephrosis → renal infection

13. Endocrinopathy in Endometriosis
 Corpus luteum insufficiency
 Luteolysis due to ↑ PGF.
 ™
Luteinized unruptured follicle (LUF)
 Anovulation
 ™
Elevated prolactin level
 Double LH peak.

14. Staging
Endometrios is should be staged appropriately.
 To predict prognosis.
 To choose therapy.
 To evaluate the treatment protocol.
The stage is determined by adding specific
points given to each.

15. American Fertility Society scoring
system of endometriosis (revised)
Peritoneum
Endometriosis < 1 cm 1–3 cm > 3 cm
Superficial 1 2 4
Deep 2 4 6
Ovary
R Superficial 1 2 4
Deep 4 16 20
L Superficial 1 2 4
Deep 4 16 20
Posterior
cul-de-sac
obliteration
Partial Complete
4 40

16. Ovary
Adhesions < 1/3
Enclosure
1/3–2/3
Enclosur
e
> 2/3
Enclosur
e
R Filmy 1 2 4
Dense 4 8 16
L Filmy 1 2 4
Dense 4 8 16
Tube
R Filmy 1 2 4
Dense 4* 8* 16
L Filmy 1 2 4
Dense 4* 8* 16
* If the fimbriated end of the fallopian tube is completely
enclosed, change the point assignment to 16.

17. Stage Severe Score
I Minimal 1-5
II Mild 6-15
III Moderate 16-40
IV Severe >40

18. Treatment
Preventive
• To avoid tubal patency test
• Avoiding pelvic examination
should not be done during or
shortly after menstruation.
• Married women with family
history are encouraged to
complete the family.
Curative
• To minimize pelvic pain
and dyspareunia
• To improve the fertility
• To prevent recurrence

19. Pelvic Endometriosis
 Expectant Management (observation only)
 Medical Therapy
• Hormones • Others
 Surgery
• Conservative • Definitive
 Combined Therapy
• Medical • Surgical

20. Expectant Treatment
 Some form of treatment is often needed
regardless of the clinical profile and to
arrest the progress of the disease.
 In women with minimal to mild
endometriosis role of any treatment is
controversial.

21. Case selection for expectant treatment
 Minimal endometriosis with no other abnormal
pelvic finding
 Unmarried
 Young married who are ready to start family
 Approaching menopause

22. Protocols for Expectant
Management
 Observation
Ibuprofen 800–1200 mg
Mefenamic acid 150–600 mg.
 The married women are encouraged to have
conception.

23. Hormonal Treatment
Drugs Dose Mechanism
Combined estrogen
progestogen
1–2 tablets Pseudopregnancy
Progestogens
Oral
• Medroxyprogesterone
acetate
10 mg TDS Pseudopregnancy
• Dydrogesterone 10–20 mg daily
• Norethisterone 10–30 mg daily
IM
• Medroxyprogesterone
150 mg 3 months
IUCD
• Levonorgestrel-
releasing-IUCD

24. Danazol 400–800 mg orally in 4
divided
doses × 6–9 months
Pseudopregn
ancy
Gestrinone 1.25 or 2.5 mg twice
a week × 6–9 months
Pseudopregn
ancy
GnRH
analogues
Leuprolide 3.75 mg IM
monthly × 6 months
• Naferelin 200 μg
intranasally daily × 6
months
• Goserelin 3.6 mg depot
IM
monthly × 6 months
Medical
oophorectomy

25. Surgical Management
Indications
 Endometriosis with severe symptoms
unresponsive to hormone therapy.
 Severe and deeply infiltrating endometriosis to
correct the distortion of pelvic anatomy.
 Endometriomas of more than 1 cm.
 Surgery may be conservative or definitive.

26. Conservative surgery
 Done to preserve the reproductive function.
 Laparoscopy done to destroy endometriotic
lesions by excision or ablation
 Laparoscopic uterosacral nerve ablation
(LUNA) is done when pain is very severe.

27. Definitive surgery
hysterectomy with bilateral savlpingo-
oophorectomy along with resection of the
endometrial tissues as complete as possible

28. Combined Medical and Surgical
 Aims at reduction of the size and vascularity of the
lesion which facilitate surgery.
 The idea of postoperative hormonal therapy is to
destroy the residual lesions left behind after
surgery and to control the pain.
 Duration of therapy is usually 3–6 months
preoperatively and 3–6 months postoperatively.

29. ENDOMETRIOSIS AT SPECIAL
SITES
 Abdominal scar
 Umbilicus
 Bladder and ureter
 Gut
 Cervix and vagina
 Lung

30. Thank you ..