Endometriosis

Endometriosis
Def: it is d occurance of endometrial tissue outside d cavity of uterus. Incidence is about 10.
Etiology:
1. Age : common in childhood period.
2. Marriage late marriages .
3. Higher socioeconomic class.
4. Infertility.
5. Genetic and family tendencies.
6. Retrograde menstruation., implantation and spread.
7. Coelomic metaplasia theory.
8. Metastatic theorey, histogenesis by induction.
9. Presence of oestrogen.
10.Immunological: impaired T cell nd NK cell activity.
11 genetic, vaginal or cervical atresia.
Sites:
ovaries, cul-de-sac ,along uterosacral ligament, peritoneum over bladder, sigmoid colon, uterus nd appendix.
Pathology:
Area appears dark red, bluish, or black cystic area adherant to site. Peritoneal cavity contains yellowish brown fluid in d cul-de-sac containing prostaglandins responsible for pain. Powder-burnt areas r d inactive lesions seen scattered over d pelvic peritoneum. Chocolate cyst of ovaries r most important manifestation of endometriosis. Inner surface of cyst wall is vascular nd contains areas of dark brown tissue.
Histology: lining epithelium is columnar. Beneath epithlm is pseudoxanthoma cells which may b large macrophages or scavenger cell.

Classification.
Revised American Fertility society classification.
This is based on d appearance,size,depth of peritoneal nd ovarian implants, presence nd extent of adnexal adhesions, nd d degree of obliteration of d pouch of douglas.

Stage1  (minimal)     score 1 - 5
Stage2  (mild)        score 6- 15
stage3  (moderate) score 16-40
stage4  (severe)   score  > 40
  Peritoneal endometriosis
                 <1cm 1-3cm >3cm
 superficial    1     2      4
 deep           2    4       6
  Ovarian endometriosis
Rt side-
 superficial    1     2      4
 deep.          4    16      20
Left side-
 superficial .  1     2     4
 deep.          4    16    20
Posterior cul-de-sac obliteration.Partial (4)
complete (40).

Ovarian adhesions

          <1/3E  1/3-2/3E  >2/3E
(E: Enclosure)
Rt side  
 flimsy.   1      2            4
 dense.  4      8           16
left side
 flimsy    1      2            4
 dense.   4     8            16

Tubal adhesion
Rt side
  flimsy  1   2   4
  dense 4   8   16
left side
  flimsy   1   2  4
  dense  4   8  16

clinical features
sympt
1 dysmenorrhea:most common symtm. Pain begins b4 d onset of menstrn, builds up continuosly until flow begins nd decreases after.
2 abdmnl pain: lower abdmnl pain suddn severe pain may indicate ruptured chocolate cyst.
3 dyspareurnia: involvmnt of cul-de-sac nd uterosacral ligament fixes uterus contributing to dyspareunia.
4 infertility due to tubal dysfunctn n dyspareunia.
5 menorrhagia
6. Chr pelvc pain due to prstgln E2 present in d brownish yellow peritoneal fluid.
7 other sympt.
Urinary: dysuria, haematuria , hydronephrosis.
Bowel sympt: painful defecation, diarrhoea, nd melaena during menstruation. Constipation.

Examination.(signs)
1. Abdmnl examintn: cystic swelling of chocolate cyst of ovary.
2. Speculum examination: bluish or blackish puckered spots in post fornix is pathognomic.
3. Vaginal examintn.
 Tender fixed retroverted uterus. Cobblestone feel of uterosacral ligament.

D/D
1. Chr PID.
2. Uterine myoma.
3. Ovarian malignant tumour.
4. Rectal carcinoma.

Investigation:
1. Laparoscopic finding: powder burn puckered black spots, chocolate cyst nd dense adhesions with yellow brown peritoneal fluid.
2. CA 125: raised more than 35 U/ml in endometriosis. Level is directly proportional to extent of endometriosis. It is glyoprotein.
3. Ultrasound nd MRI: irregular nd multiple cysts with thick wall are observed.

Prophylaxis:
1. Avoidance of classical caesarean section nd hysterectomy.
2. Low dose oral contraceptive pills.
3. Operation on genital tract after menstruation.
4. Tubal patency test should not be done in premenstrual phase..

Management of endometriosis..
1. Asymptomatic with minimal endometriosis. Observe for 6-8 months. Investigate fertility.

2. Symptomatic case:
a. Drug treatment
* Combined oral contraception.
* Oral propestogens: these
  drug exert antioestrogenic        effect nd their continuous
  admnstrn causes endometrial
  atrophy.
   Drugs used: norethisterone 5   to 20 mp daily.
*Androgens(Danazol):200 to
  800mg daily for 3 to 6 month
  starting on first day of menses.
*gonadotropin releasing
  hormone: synth analogue of
  GnRH is doses of 10 to 20micro
  g IV twice daily.
*lectrozol.

b Minimal invasive therapy:
Laparoscopy- destruction by cautery, laser.
Vaporization.
- excision of cyst.
-adhesiolysis.
-presacral neurectomy
-LUNA(laproscopic uterosacral nerve ablation)

4. Surgery.
Laparotomy.
A. Incision of chocolate cyst, and removal of lining.
B. Salpingo-oopherectony.
C. Hysterectomy and bilateral salpingo-oophorectomy.
D. Exicision of scar endometriosis.