1 Endometriosis *Is the presence of endometrial glands and stroma outside the endometrial cavity and walls *Deposits proliferate during the menstrual cycle, brake down & bleed with menstruation, causing local inflammatory reaction *Fibrosis & distortion of the tissue affected with dense scarring. Benign

2 Endometriosis Hormone dependant Responds to estrogenRegress after menopause, oopherectomy and during pregnancy

3 Endometriosis EtiologyUnknown Theories Retrograde menstruation Coelomic epithelium transformation Lymphatic and vascular spread Genetic and immunologic factors

4 Endometriosis EpidemiologyDisease of reproductive age group Affect 5-15% of women Diagnosed in 20-30% of women investigated for infertility More in women whose first degree relative have the disease Often diagnosed incidentally

5 Endometriosis High social class women in their thirties and infertile!Can be diagnosed in any type of women and all age groups

6 Endometriosis Sites More commonly in the dependant part of the pelvisOvaries 2/3 of women Broad ligament Peritoneal surface of Cul-de-sac and uterosacral ligaments Rectovaginal septum Rectosigmoid colon Distant and laparatomy scars

7 Endometriosis PathologyGross Hemorrhagic vesicle Free Papule and later nodule Enclosed White nodules or flattened fibrotic scar Healed Ovarian endometrioma is an enclosed hemorrhagic cyst of variable sizes

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12 Endometriosis HistopathologyActive endometrial glands and stroma Blood filled cystic lesions Fibrosis with glands only no stroma Adhesion formation

13 Endometriosis SymptomsAccording to site No relation between extent of the disease and severity of the symptoms Often discovered incidentally

14 Endometriosis SymptomsFemale reproductive tract Dysmenorrhea Lower abdominal and pelvic pain Dyspareunia Accident to endometriotic cyst Low back pain Infertility Menstrual irregularity !

15 Endometriosis SymptomsUrinary tract Cyclical haematuria / dysuria Ureteric obstruction Gastrointestinal tract Dyschezia Cyclical rectal bleeding Intestinal obstruction

16 Endometriosis SymptomsSurgical scar and umbilicus Cyclical pain and bleeding Lungs Cyclical haemoptysis Haemopneumothorax`

17 Endometriosis Clinical findingsOften Negative Suggested by Thickening and nodularity of uterosacral L. Tenderness in POD Ovarian mass/ masses Fixed retroverted uterus Tender nodule in the cervix, umbilicus or scar

18 Endometriosis InvestigationsCa 125 often elevated Ultrasonography for ovarian cyst MRI

19 Endometriosis DD All causes of chronic pelvic pain Acute conditionsEctopic pregnancy Acute PID Complicated ovarian cyst Acute appendicitis and other surgical emergencies

20 Endometriosis DiagnosisDirect visualization of the lesion Laparascopy Laparatomy Histopathology to confirm the diagnosis

21 Endometriosis TreatmentNon-steroidal anti-inflammatory agents Induce Amenorrhea: Pseudopregnancy Induce Amenorrhea: Pseudomenopause Surgery

22 Endometriosis TreatmentPseudo-pregnancy Combined OCP continuous Cyclical ?? of limited value Side effect Synthetic progestogens: Medroxyprogesterone acetate and dydrogesterone high doses continuous Side effect Levonorgestrel-releasing system reduces dysmenorrhoea and regress POD implants

23 Endometriosis TreatmentPseudomenopause Danazol androgen derivative 6-9 months Gestrinone, androgen derivative Both drugs have androgenic side effects GnRH agonists Menopausal symptoms, Osteoporosis ? Add back therapy

24 Endometriosis TreatmentSurgery Conservative Young patient, women seeking pregnancy, cysts >3cm in diameter Surgical excision, Laser Radical/Definitive surgery Hysterectomy and BSO

25 Endometriosis TreatmentCertainty of diagnosis Severity of symptoms Extent of the disease Fertility Age Damage to other organs

26 Endometriosis and InfertilityOvarian function Tubal function Coital function Sperm function Early pregnancy failure

27 Adenomyosis Endometrial glands deep within the myometriumUnknown etiology Different type of patient and presentation

28 Adenomyosis Multiparous women Late thirties or early fortiesSever spasmodic dysmenorrhea Menorrhagia Bulky uterus Diagnosis often histological on examination of hysterectomy sample

29 Adenomyosis TreatmentInduce amenorrhea Symptoms recur once treatment is stopped Hysterectomy is the only definitive treatment