Endometriosis

Endometriosis

ENDOMETRIOSIS • Occurrence of ectopic endometrial tissue outside the uterine cavity. • Endometriosis is sometimes referred to as ‘external endometriosis’ to distinguish it from adenomyosis (which is sometimes referred to as internal endometriosis.

• These deposits are usually functional and react to the stimulus of ovarian steroids and show cyclical changes.

Incidence • Age : Commonly 20s & 30s (Reproductive age) • The true incidence of endometriosis is not known since laparoscopy or laparotomy is necessary for confirmation of diagnosis. • Higher incidence within affected families (suggesting a genetic predisposition)

• Common sites : • 1. Ovary (most common site) - usually bilateral • 2. Pelvic peritoneum • 3. Rectovaginal pouch & septum • 4. Uterine lig (Uterosacral & broad ligament) • 5. Sigmoid colon

• • • • • • •

Less common sites : 1. Bladder 2. Appendix 3. Round ligament 4. Umbilical region 5. Lower abdominal scars 6. Pleural or pericardial cavities

PATHOLOGY • Gross : Ectopic deposits varying in number from a few in one locality to large numbers distributed over the pelvic organs and peritoneum. • Commonest appearance of a typical lesion Round protruding vesicle/cyst - from blue to black to brown. The variation of colour is due to cyclic hemorrhage with subsequent breakdown of the hemoglobin.

• endometriosis almost always contains functioning endometrium, which undergoes cyclic bleeding. • In the ovarian endometriosis also known as endometrioma, if the blood has been present for some time, it will become thick and dark chocolate cyst. • The presence of chocolate cyst on the ovaries is not diagnostic of endometriosis although endometrioma is the commonest cause of bilateral chocolate cysts.

Ectopic endometrial tissues -> periodic bleeding -> accumulations of blood -> vesicles/cyst formation -> Heal @ seepage of blood -> organization of blood -> Wide spread Fibrosis, leading to: • Adherence of pelvic structures • Sealing of the tubal fimbriated ends • Distortion of the oviducts and ovaries eventually tubal blockage.

Microscopic : Nest of endometrial tissue -> Typical endometrial tubular glands and stroma cells. There may also be cystic glandular hyperplasia. The histologic diagnosis at all sites depends on finding within the lesions 2 of the following 3 features : • Endometrial glands • Stroma • Hemosiderin pigment

AETIOLOGY Numerous theories. 1. Over-spill (Regurgitation) theory - Sampson’s theory This suggests that minute fragments of endometrium pass along the fallopian tubes during menstruation and spill into the pelvic part of the peritoneal cavity, becoming implanted in various structures.

2. Metaplastic theory - Meyer’s theory An alternative theory is that of coelomic metaplasia. The Mullerian ducts are originally derived from an infolding of the coelomic epithelium, and it is suggested that endometriosis may result from metaplasia of the peritoneal endothelial cells if exposed to a chronic irrittant such as menstrual debris.

3. Dissemination theory - Halban theory Dissemination through vascular or lymphatic channels. This has been put forward to explain distant site of endometriosis e.g. lungs, pericardial cavity

Risk factors Several factors leads to greater risk of developing endometriosis, such as: • Nulliparous • Menarche at an early age • Going through menopause at an older age • Short menstrual cycles — for instance, less than 27 days • Having higher levels of estrogen in body or a greater lifetime exposure to estrogen body produces • Alcohol consumption • One or more relatives (mother, aunt or sister) with endometriosis

• Endometriosis never appears before puberty and it regresses after menopause. • In those who has endometriosis, the disease regresses when they happened to become pregnant. However, they may recur years later

Clinical features The clinical features of endometriosis are varied, and the presentation depends upon the site of growth, as well as its severity. Endometriosis has classically been characterized as including the triad of : • Dysmenorrhea • Dyspareunia • Infertility

1) Dysmenorrhea & pelvic pain - Pain (premenstrually and during menstruation) - frequently localized abdominal pain, may be generalized. • Most common symptom. • May be d/t the appearance of blood in the peritoneal cavity from: • Bleeding endometiral implants • Reflux menstruation. 2) Menorrhagia 3) Deep dyspareunia - when the uterosacral lig. or the rectovaginal pouch or septum are involved. 4) Infertility - Extensive endometriosis may produce marked scarring and distortion of anatomy including : • Tubal occlusion - prevent the ovum from entering the fallopian tube • Periovarian adhesions - prevent release of the ovum from the Graafian follicle. Pelvic mass ( endometrioma) Tender and nodular uterosacral ligament

 Ovarian endometriosis pain, dysmenorrhoea, menorrhagia, deep dyspareunia & infertility  Endometriosis of the rectovaginal dyspareunia or rectal pain

septum

- deep

 Bladder - frequency of micturition, dysuria, hematuria, suprapubic pain

 Bowel obstruction

dyschezia, rectal bleeding, and intestinal

 Endometriosis of the abdominal scar  Pulmonary - chest pain & cough + hemoptysis

DIAGNOSIS • Serum Ca125- TRO epithelial ovarian malignancy. Useful indicator of recurrence after treatment. • USG – to look for adnexal/pelvic mass • Direct visualisation via laparoscopy /laparotomy - the definitive diagnosis is established by these surgical procedures. Biopsy performed for histological diagnosis.

TREATMENT • In most cases a choice has to be made between hormonal treatment and surgery; in relatively young patients treatment with hormones is tried first.

Hormonal therapy • The aim of treatment is to reduce the stimulus of estrogen on the ectopic endometrium either by reducing estrogen production or oppose its action. 1. Progestogens (large doses for 9-12 months) - to induce pseudo-pregnancy, inducing the ectopic endometrium would undergo decidualisation which ultimately would be destroyed by necrosis and heal by fibrosis. 2. Danazol or Gestrinone  Anti-estrogenic + antiprogestogenic + Gonadotrophin inhibitor  inhibits ovulation  endometrial atrophy

3. Agonist of GnRH  Are given continuously to desensitize the pituitary receptors for the GnRH   FSH and LH  creating pseudo-menopausal hypoestrogenic state

4. NSAIDS to treat dysmenorrhea and pelvic pain

Surgical

Indicated when failed medical treatment or presence of endometrioma more than 3 cm 1.Small lesions  Laparoscopy or laparotomy  diathermy cauterization or excision of localized disease 2.Widespread deposits  TAHBSO - Total hysterectomy with bilateral salpingooophorectomy  for women who no longer wish to become pregnant.

Complication • • • • •

Infertility Chronic pelvic pain Rupture of endometritic cyst Urinary or intestinal tract involvement Malignant transformation – Malignant transformation can occur in areas of endometriosis. The usual lesion is an adenoacanthoma. Others : Endometrial ca, adenosquamous ca, etc

ADENOMYOSIS

• Refers to the presence of nests of endometrial glands and stroma in the myometrium of the uterine wall. • Adenomyosis is sometimes referred to as endometriosis interna to distinguish it from endometriosis externa, ectopic endometrium beyond the uterine serosal layer

Macroscopic • 2 forms : Diffuse (commoner) or localized • Diffuse - the uterus is diffusely enlarged, but only rarely to a size greater than 12 weeks gestational size. • Localized - The myometrium is locally thickened. A tumour-like mass can be seen but there is no capsule (not well circumscribed).

• Usually a/w leiomyoma (50%) and endometriosis (15%)

Risk factors • Prior uterine surgery, such as a C-section or fibroid removal • Multiparous • Middle age (35-50)

Clinical features • Chronic pelvic pain (77%) • Heavy menstrual bleeding (40-60%), which is more common with in women with deeper adenomyosis. Blood loss may be significant enough to cause anemia, with associated symptoms of fatigue, dizziness, and moodiness. • Painful cramping menstruation (15-30%) • Painful vaginal intercourse (7%) • Pressure on bladder • Uterine enlargement (30%), which in turn can lead to symptoms of pelvic fullness.

• Tender uterus

Investigations • Transvaginal ultrasound abnormally dense or especially varied density within the myometrium, myometrial cysts - pockets of fluid within the smooth muscle of the uterus, globular, enlarged, and/or asymmetric uterus • Hysterosalpingography multiple small spicules extending from endometrium into myometrium with saccular endings.

Management Medical treatment • NSAIDs: Nonsterioidal anti-inflammatory drugs, such as ibuprofen and naproxen, are commonly used for pain relief for dysmenorrhea. • Tranexamic acid for heavy menstrual bleeding

Surgical treatment • Hysterectomy ( complete cure) • Endometrial ablation techniques result in sterility and therefore are suitable only for women who have completed their childbearing. The techniques either include physical resection and removal of the endometrium through a hysteroscope, or focus on ablating or killing the endometrial layer of the uterus without its immediate removal. Endometrial ablation and resection techniques are most appropriate for shallow adenomyosis.