Transcript Endometriosis

Endometriosis
DR.
AHMED JASIM
A. PROF
Endometriosis
• Endometriosis is
presence of viable
endometrial tissue
outside the lining of
uterine cavity. It is
one of the
commonest benign
gynecological
conditions and it is a
chronic and
progressive disease.
Prevalence:
• The exact prevalence of endometriosis is
not known, since many women may have
the condition and have no symptoms.
Endometriosis is estimated to affect from
3% to 18% of women. It is one of the
leading causes of pelvic pain and reasons
for laparoscopic surgery and
hysterectomy. .
Aetiology of endometriosis:
• The cause of endometriosis is unknown.
Several theories exist to explain the
process through which endometriosis
develops. These are:
• 1. Retrograde menstruation with
implantation.
1. Retrograde menstruation with
implantation.
Retrograde menstruation
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2. Coelomic epithelium transformation.
3. immunological factors.
Retrograde menstruation
4. Genetic predisposition. (more
commonly in the 1st degree relatives of
affected women).
• 5. Vascular and lymphatic
spread.(endometriosis
in the brain
and other organs distant from the pelvis).
• 6.direct transfer of endometrial tissues
during surgery.(episiotomy or Cesarean
section scars).
• The most widely accepted explanation is:
• Retrograde menstruation with implantation
of endometrial fragments in conjunction
with peritoneal factors to stimulate cell
growth.
Pathology:
• Endometrium outside uterine cavity responds to
cyclic changes from ovarian hormones. During
each menstrual cycle the endometrial deposit
proliferates and then breaks down and bleeds,
causing a local inflammatory reaction which may
followed by a prolonged period of time by
fibrosis. Chronic repition of this process disrupts
and distorts the affected tissue and typically
dense scar tissue and adhesion may form that
can distort a woman’s internal anatomy. In
advanced stages, internal organs may fuse
together, causing a condition known as a "frozen
pelvis."
• The disease varies from a few, small
lesions on otherwise normal pelvic organs
to solid infiltrating masses. The cells of
endometriosis attach themselves to tissue
outside the uterus and are called
endometriosis implants.
• Endometriosis typically appears as
superficial ‘powder-burn’ or ‘gunshot’
lesions, black, dark-brown or bluish
puckered lesions, nodules or small cysts
containing old haemorrhage surrounded
by a variable extent of fibrosis on the
ovaries, serosal surfaces and peritoneum.
• Atypical lesions are also common.
Endometriomas (chocolate cysts ):
• Are retention cysts containing tary material
that develop as a consequence of ovarian
endometriosis. It may be multiple and very
large. It responds to ovarian hormones,
bleeding may occur in endometriosis
forming small blood cyst, in the ovary. It
become large up to 10 cm and tend to be
bilateral.
Upon opening a chocolate cyst, irregular brown
areas are observed
• Microscopically:
• Showed the typical endometrial tubular
glands and stroma cells.
• a small cluster of endometrial glands and
stroma with hemorrhage are seen at the left
near the surface of the fallopian tube. The
lumen of the tube is at the right. This is a
focus of endometriosis .
The squeal of endometriosis:
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It include:
1. chronic pelvic pain
2. severe dysmenorrhoea
3. infertility.
Sites of Endometriosis:
• *Endometriosis lesions most commonly found in
the pelvic cavity.
• on the surface of ovary, pelvic peritoneum, the
fallopian tubes, on broad ligaments, the pelvic
sidewall, uterosacral ligaments, the Pouch of
Douglas, and in the rectal-vaginal septum.
• *it can be found in caesarean-section scars,
laparoscopy or laparotomy scars, But these
locations are not so common.
• *In even more rare cases, endometriosis has
been found inside the vagina, inside the bladder,
bowel, intestines, colon, appendix, rectum, on
the skin, even in the lung, spine, and brain.
reddish-brown to bluish appearance.
the gross appearance of "powder burns".
Small foci are seen here just under the
serosa of the posterior uterus in the pouch
of Douglas.
Nodular endometrial lesions in the posterior
.cul-de-sac
Cystic implants adjacent to the right ovary;
.note bluish appearance
Ovary with endometrioma
.Hemorrhagic lesions overlying the right ureter
Extensive endometriosis in the ovarian fossa.
.Lesions have a petechial appearance
,Diffuse endometriosis is seen in the cul-de-sac
Puckered black lesions are typical of
endometriosis
Classification systems:
• The 4 stages (classification) of
endometriosis (minimal, mild,
moderate or severe) are used to
describe the anatomic location and
the severity of the disorder.This
system was designed to assist in the
prognosis and management of
patients undergoing surgery for
infertility.
Risk Factors for Endometriosis:
• A. Greater exposure to menstruation as in:
• 1. Increasing age (up to menopause).
• 2. Shorter menstrual cycle length (less than 27
days).
• 3. Longer duration of menstrual flow (greater
than 7 days).
• 4. Heavy menstrual flow.
• 5. Delaying pregnancy until an older age.
• 5. Low or no parity.
• B. First-degree relative (mother, sister, daughter)
with endometriosis.
• c. Increased peripheral body fat.
• Factors which may be protective from
developing endometriosis:
• Oral contraceptive use (current and
recent) may be protective.
• Smoking.
• Exercise.
Clinical feature:
• The typical patient with
endometriosis is in her reproductive
years, (commonly in her 30s) and
characteristically are nulliparous,
and infertile or delayed their child
bearing. Endometriosis never
appears before puberty and it
regresses after menopause.
• Endometriosis is more commonly found in white
women, tall, thin women with a low body mass
index (BMI).
• Endometriosis is a common condition with many
diverse manifestations and a clinical course that
is highly variable and unpredictable depending
upon site and activity of the disease.
• Endometriosis should be suspected in any
woman with the triad of dysmenorrhoea,
dysparunia and infertility.
Symptoms:
• The symptoms of pelvic endometriosis depend
on the site and the activity of the disease.
• a. Asymptomatic:
• many affected women are asymptomatic in
which case the diagnosis is only made when the
pelvis is inspected for an unrelated reason, for
example sterilization. One-third of women with
endometriosis are asymptomatic.
b. symptomatic:
• 1.Pain is the most common symptom, and many
types of pain are found:
• a. Severe secondary dysmenorrhoea.
• b. severe deep dyspareunia.
• c. ovulation pain is sometimes sever in mid cycle.
• d. Pelvic discomfort, lower abdominal pain,
backache.
• e. acute abdominal pain in rupture ovarian
endometriomas which leads to
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reactive peritonitis which is acute abdominal
emergency requiring
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laprotomy.
• For many women, the pain of endometriosis is
so severe and debilitating that it impacts their
lives in significant ways. The pain intensity can
change from month to month, and vary greatly
among women. Some women experience
progressive worsening of symptoms, while
others can have resolution of pain without
treatment.
• There is little correlation between disease stage
and the type, nature and severity of pain
symptoms.
2. infertility may be the main
complaint.
• The reasons for a decrease in fertility are
not completely understood, but might be
due to both:
• a. The presence of endometriosis may
distort normal anatomical structures, such
as fallopian tubes and may interfere with
oocyte pick up.
• b. production of hormones and substances
that have a negative effect on ovulation,
fertilization and/or implantation of the
embryo.
• Whether endometriosis causes subfertility
or not is controversial. A causal
relationship with minimal–mild disease is
much less certain.
3. Menstrual disturbance:
• It can cause abnormal uterine bleeding:
• Menorrhagia in case of :
– adenomyosis
– ovarian function is altered by bilateral
endometriomas.
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b. Irregular uterine bleeding.
c. Polymenorrohea. (short cycles)
d. Prolonged bleeding.
4. Other symptoms related to
endometriosis include:
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lower abdominal pain.
diarrhea and/or constipation.
low back pain.
blood in the urine (hematuria at time
of menstruation).
• 5. Rare symptoms of endometriosis
include chest pain or coughing blood
(haemoptisis) ?due to endometriosis in the
lungs and headache and/or seizures due
to endometriosis in the brain.
Examination:
• Physical examination should be
performed during early menses, when
implants are likely to be largest and
most tender.
• A. most women with endometriosis
have normal pelvic findings
• B. The examination may reveal one or
more of these which is suggestive of
endometriosis:
• *visible lesions (Bluish nodule) are seen in
vagina or on cervix. Such nodules are
reliably detected when the examination is
performed during menstruation. It confirm
the diagnosis.
• *adnexal and uterine tenderness.
• *pelvic masses as Enlarged ovaries due to
endometriomas.
• *a fixed retroverted uterus (In advanced
and destructive disease).
• *nodularity and tenderness along the
uterosacral ligaments.
• *A rectovaginal examination is required to
identify uterosacral, cul-de-sac or septal
nodules.
Differential diagnosis:
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Adenomyosis.
Pelvic Inflammatory Disease (PID).
Uterine fibroid .
Carcinoma of ovary.
Carcinoma of colon or rectum.
Pelvic congestion syndrome.
Differential diagnosis to Rupture of
endometriotic cyst which presents
as an acute abdominal emergency
are:
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Rupture ectopic pregnancy.
Ovarian cyst torsion.
Ovarian cyst haemorrhage.
Acute salpingitis.
Other causes of acute abdomen.
Investigations:
• Making a diagnosis on the basis of
symptoms alone is difficult as the
presentation is so variable and mimic
other disease. Consequently, there is
often a delay of several years between
symptom onset and a definitive diagnosis
at laparoscopy.
Non invasive test:
• None of these tests can definitively
confirm or dismiss the presence of
endometriosis lesions. These are:
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• *Ultrasound examination:
• trans-vaginal ultrasound is a useful tool to
diagnose and exclude ovarian
endometriomas but it has no value for
peritoneal disease.
*Serum cancer antigen 125 test
(CA-125):
• *Serum cancer antigen 125 test (CA-125):
• CA-125 measurement has no value as a
diagnostic tool for minimal–mild
endometriosis.
• Serial measurements are useful as
prognosticators of treatment outcome.
However, normal post-treatment values do
not mean that endometriosis is absent.
*MRI scans:
• Beneficial in imaging ovarian cyst or
invasion of surrounding organ.
Invasive investigation:Laparoscopy
• Laparoscopy is the gold standard for diagnostic
purposes, unless disease is visible in the vagina
or elsewhere. Laparoscopy is considered the
primary diagnostic modality for endometriosis. The
classic lesions are blue-black or have a powderburned appearance or atypical lesion.
• Visual inspection is usually adequate but
histological confirmation of at least one lesion is
ideal, and mandatory if disseminated peritoneal
endometriosis (DIE) or a >3 cm diameter
endometrioma is present.
• The entire pelvis should be inspected
systematically, and good practice is to document
in detail.
Treatment:
• Treatment must be individualized, taking
into account these factors which influence
choice of treatment and these are :
• 1. Woman’s age.
• 2. Fertility status.
• 3. Nature of symptoms.
• 4. Severity of disease.
• 5. Previous treatments.
1.expectant management:
• which is essentially a "wait-and-see"
approach. It is recommended for:
• 1.asymptomatic women.
• 2. infertile patients with superficial disease
and mild symptoms.
• 3. older women approaching menopause.
• Expectant management consists of a
period of observation with no treatment
except the use of antiprostaglandin
medications to relieve pain.
2. medical treatment:
• *Non-steroidal anti inflammatory agents:
• Are potent analgesic and are helpful in
reducing severity of dysmenorrhoea and
pelvic pain but have no specific impact on
disease and its progression.
*hormonal therapies:
• Hormonal treatments have traditionally
attempted to mimic pregnancy or the
menopause. It temporarily shrink
endometrial lesions and relieve symptoms.
Peritoneal lesions decrease in size during
therapy but reappear rapidly following
therapy; Endometriomas rarely decrease
in size and adhesions will be unaffected.
• It may include:
• a. combined oral contraceptive pill (COC):
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continuous use or extended cycle use
(every 3 months).
2. Progestogens:
• 2. Progestogens:
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It produce pseudo decidualization of
endometrium. Oral treatment start on the
fifth day of menstruation and continuo for
six months and may need to increase
dose. These are: Norethisterone
(primolut-N), medroxy progesterone
acetate (Provera), dydrogestrone. Or can
use Mirena (IUD).
3. GnRH-analogues (agonists and
antagnosists) induce pseudomenopause.
. It used with Add-back therapy which involves
taking one of the following medications at the
same time as a GnRH agonist: a low-dose
oestrogen, a low-dose progestin, or tibolone
alone. Add-back therapy can reduce the
menopausal-type side effects of GnRH agonist
therapy and preventing or minimizing the thinning
of the bones associated with treatment with a
GnRH agonist alone.
• 4. Danazol 400-800 mg daily course 3-6
months. Androgenic side effect
• 5. Gestrinone 2.5mg twice weekly- course
3-6 months. Androgenic side effect
• 6. Aromatase inhibitors.
Hormonal treatment for subfertility
caused by endometriosis:
• Hormonal treatment for subfertility associated
with minimal–mild endometriosis does not
improve the chances of natural conception.
Clearly treatment can do more harm than good
because of the lost opportunity to conceive.
• In more advanced disease, there is no evidence
of an effect on natural conception, but there may
be a role for hormonal treatment as an adjunct
to assisted conception.
3.surgery:
Conservative surgery
• The laparoscopic approach is the method of
choice for treating endometriosis conservatively.
The aim is to destroy visible endometriotic
implants, endometriomas, and lyse peritubal and
periovarian adhesions and to restore normal
anatomy. excision or coagulation is preferable
for typical lesions. Excision is the preferred
method for endometriomas.
• oophorectomy if large one and patient not need
fertillity.
• Fertility patients should be counseled about the
risks of reduced ovarian function after
endometrioma excision and the loss of an ovary.
Laparoscopic excision of nodular endometrial
lesions overlying the rectum
Definitive surgery:
• Endometriosis surgery can be complex and
difficult, and surgeons often need specialized
skills and expertise to perform such surgery.
• It is indicated when there is:
• Severe symptomatology.
• Progressive disease.
• Women complete their families.
• Treated by hysterectomy and bilateral salpingooopherectomy.
• Patients can receive HRT subsequent to surgery
after 6 months or more from surgery.
the gross appearance of "powder burns".
Small foci are seen here just under the
serosa of the posterior uterus in the pouch
of Douglas.
4. Combined Medical-Surgical
Therapy
• *Preoperative medical treatment by GnRH
agonists or Danazol use in women with
advanced endometriosis as it can:
• decrease the extent of endometriosis,
making it easier to achieve complete
resection of endometriotic implants by
laparascopy is facilatated.
• decreases the size of endometriomas,
which can facilitate surgery.
• *Postoperative after conservative surgery
giving GnRH agonists or Danazol to
improve patient outcomes.
• Three outcomes are generally used to
assess treatment efficacy:
• 1. the anatomic manifestation of the
disease, can be assessed
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laparoscopically before and after
therapy to determine treatment
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efficacy.
• 2. pain symptomatology.
• 3. infertility status.
Endometriosis and pregnancy
• Pregnancy generally leads to an
improvement in endometriosis symptoms,
particularly during the latter months of
pregnancy (due to the high levels of
progesterone and due to lack of
menstruation during pregnancy). However,
some women experience a worsening of
symptoms, particularly during the first three
months ( may be due to rapid growth of the
uterus lead to stretching and pulling of
adhesions, may be due to high levels of
oestrogen).
Endometriosis and pregnancy
• For most women, the beneficial effects of
pregnancy are only temporary. Many
women will experience a recurrence of
their disease and its symptoms within a
few years, and some will experience a
recurrence soon after resuming their
periods.
Endometriosis and breastfeeding
• Regular breastfeeding inhibits the release
of oestrogen by the ovaries, which
suppresses ovulation and the growth and
development of the endometriosis and
lead to remission of symptoms
Adenomyosis
• It is disorder in which benign invasion of
endometrium into the myometrium. These
endometrium is responsive to steroid
hormones and bleeding will occur each
month.
Aetiolgy:
• Its cause is not known.
• It may be triggered by weakness in
smooth muscle of myometrium by
increased intrauterine pressure or by
surgical trauma as in repeated
pregnancies, history of miscarriage,
induced abortion and caesarean section.
Pathology:
• Uterus uniformly enlarged (symmetrical
enlargement).
• It causes localized thickening of part of
uterine wall but this is not encapsulated
and can not be shelled out of the
surrounding normal muscles (differ from
uterine fibroid).
• Microscopically:glandular tissue and
stroma in myometrium.
• Adenomyosis occurs when endometrial
glands and stroma are found in the
myometrium,
• The thickened and spongy appearing myometrial wall of
this sectioned uterus is typical of adenomyosis. There is
also a small white leiomyoma at the lower left .
Clinical feature:
• Patients are usually multiparous and the age of
45 being the commonest age of presentation
and is very rare in nulliparous women.
• Many women are asymptomatic.
• Symptomatic:
• The commonest presentation is that of
menorrhagia associated with worsening
dysmenorrhoea (increasingly severe secondary
dysmenorrhea). Patient may complain from
deep dysparunia especially pre-menstrually.
Pelvic Examination:
• Pelvic Examination:
• bulky uterus , symmetrically enlarged.
• Some time tender if peri-menstrually
examined.
Investigations:
• *Ultrasound:
• transvaginal ultrasound which is primary
modality as it shows Localized area in
endometrium.
• *Magnetic resonance imaging (MRI):
• It is more accurate in diagnosing
adenomyosis and can distinguish
adenomyosis from uterine fibroid.
• *Histopathogy of hysterectomy specimen.
Treatment:
• Medical treatment:
• (non-steroidal anti-inflammatory
drugs, combined oral contraceptives,
high dose progestrogens and the
levonorgestrel-releasing intra-uterine
system(LNG-IUS) are helpful in
relieve pain and excessive bleeding.
* surgical treatment
• Hysterectomy is the only method of curing
the problem (without oopherectomy,
unless there are specific indications for
removal of ovary).
• Endometrial ablation is relatively
contraindicated since it will fail to remove
deeply infiltrating glands and is unlikely to
be successful.