Endometriosis

here is the detail description of the topic;Endometriosis

1. Ms. SAHELI C
LECTURER
IACN
ENDOMETRIOSIS

2. INTRODUCTION
•Endometriosis is an abnormal condition in which cells
similar to those in the endometrium, the layer of the
tissue that normally covers the inside of the uterus,
grows outside of it.
•It is a major cause of chronic pelvic pain and infertility.
•Most often this is on the ovaries, fallopian tubes and
tissue around the uterus and ovaries; however in rare
cases it may also occur in other parts of the body.

3. INCIDENCE
•Endometriosis is a chronic disease that affects
between 5% to 15% of women of reproductive
age.
•However, it may be more prevalent as up to 25%
of cases are asymptomatic and can be a
secondary finding during pelvic surgery or
exploration for other reasons.

4. DEFINITION
Thepresenceoffunctioningendometrium
(glandsandstroma)insites,otherthanuterine
mucosaiscalledendometriosis.

5. SITES
•EXTRA-ABDOMINAL
Abdominal scar or hysterotomy, cesareansection,
tubectomyand myomectomy, umbilicus, episiotomy
scar, vagina and cervix.
•REMOTESITES :
They are pleura, lungs, deep tissues ofarms
andthighs.

6. MOST COMMON SITES:
•Ovary
•Pouch of Douglas
•Uterosacralligament
•Rectovaginalseptum
•Sigmoidcolon
•Abdominal scar followinghysterotomy.

7. OVARIANENDOMETRIOSIS

8. •maybeeithersuperficialordeep.
•Thesmallsuperficialdarkbluishcystscontain
alteredbloodandfromthesetheescapeofsmall
quantitiesmayresultintheformationof
adhesionstosurroundingstructures.
•Whentheadhesionsarebrokendown;thecysts
aredamagedandthechocolatematerialescapes.

9. BOWELENDOMETRIOSIS

10. •The rectum is involved, most commonly at the
rectovaginal septum, the lesions being seenon
the peritoneal surface and in the muscular layers
but rarely involving themucosa.
•Patients usually present with abdominalpain
and pelvicdiscomfort.

11. Obstructionmaybepartialorcompletedue
tofibrosis;affectingthewallofthebowel.
Mostcommonlyseenintheilealregionandthe
sigmoido-rectaljunction.

12. LOWER GENITAL TRACT
ENDOMETRIOSIS

13. •cervixandvaginaarebluishincolourand
usuallycystic.
•Thereistendernessonpalpation,especially
duringmenstruation.
•Thereferablesymptomsaredyspareunia,
dysmenorrhoeaandperhapsbleeding.

14. URINARY TRACT
ENDOMETRIOSIS

15. URINARY TRACT
ENDOMETRIOSIS
•Maybeseenoncystoscopy,mayoccurwith
associatedsymptomsoffrequency,dysuria,
hamaturiaandabdominalpain.

16. UMBILICAL
ENDOMETRIOSIS

17. UMBILICALENDOMETRIOSIS
•usuallypresentsascyclicalumbilicalpainwith
abluediscolorationatthetimeof
menstruation.
•Treatmentisdonebyexcision.

18. ENDOMETRIOSIS INSCARS

19. •Aswellinginalaparotomyorcesarean
sectionscarispainfulandtender,especially
duringmenstruation.

20. OTHERSITES
•Spread to the inguinal region by means of the
round ligament has been reported and
deposits have been found in the limbs when
painful swelling have been excised.
•Hemoptysismay be the first sign of pulmonary
endometriosis especially when it is cyclical and
associated with cyclical chest pain.

21. PATHOPHYSIOLOGYAND ETIOLOGY
RETROGRADE MENUSTRATION (SAMPSON’S
THEORY)
containing
suggestthatmenstrual
fragmentsofendometrium
blood
might
passalongthefallopiantubesinaretrograde
manner and thus reach the peritonealcavity.

22. COELOMIC METAPLASIA THEORY (MAYER AND
IVANOFF)
•Chronicirritationofthepelvisperitoneumbythismenstrual
bloodmaycausecoelomicmetaplasiawhichresultsin
endometriosis.
•Alternativelythemulleriantissueremnantsmaybetrapped
withintheperitoneum.
•undergometaplasiaandbetransformedintoendometrium.

23. DIRECTIMPLANTATION :
•Accordingtothetheory,theendometrialordecidual
tissuesstarttogrowinsusceptibleindividualwhen
implantedinthenewsites.
•Such sites are abdominal scar following
hysterectomy, cesarean section, tubectomy and
myomectomy.
•Endometriosis at the episiotomy scar, vaginal or
cervical site can also be explained with thistheory.

24. Lymphatic and vasculardissemination
(Halban):
•It may be possible for the normalendometrium
to metastasise the pelvic lymph nodes through
draining lymphatic channels of the uterus.
•This could explain the lymph node
involvement.

25. PATHOGENESIS
•Theendometriumintheectopicsiteshasgotthe
potentialitytoundergochangesundertheactionof
ovarianhormones.
•While proliferative changes areconstantly
evidenced, the secretory changes are
conspicuously absent inmany.

26. •Cyclic growth and shedding continue till menopause.
The periodically shed mayremain encysted or else,
the cyst becomes tense and ruptures.
•As the blood act asirritant, there is dense tissue
reaction surrounding the lesion with fibrosis.
•If it happens to occur on the pelvic peritoneum,it
produces adhesion and puckering of the peritoneum.

27. •Ifencysted,thecystenlargeswithcyclicbleeding.
•Theserumgetsabsorbedbetweentheperiodsandthe
contentinsidebecomeschocolatecoloured.
•Hencethecystiscalledchocolatecystwhich
commonlylocatedintheovary.

28. PELVICENDOMETRIOSIS
•Typicallytherearesmallblackdots,thesocalledpowderburns
seenontheuterosacralligamentsandpouchofDouglas.
•Fibrosisandscarringintheperitoneumsurroundingtheimplantsis
alsoatypicalfinding.
•Othersubltleappearancesare:redflameshapedareas,red
polypoidareas,yellowbrownpatches,whiteperitonealareas,
circularperitonealdefects.
•Theselesionsarethoughttobemoreactivethanthepowderburn
areas.

30. PERITONEALENDOMETRIOSIS
•Redendometriosiswhichischaracterizedbynumerous
proliferativeglandswithacolumnarorpseudo-stratified
epitheliumandtheglandularcomponentoftheselesions
hasverysimilarappearancestothatofnormal
endometrium.
•Theredappearanceisbroughtaboutbythelikelyrecent
implantationofretrogradelymenstruatedendometrial
cells.

31. OVARIANENDOMETRIOSIS
•likelythattheendometrialdepositbecomes
invaginatedintothesurfaceoftheovaryorit
maybethataninflammatoryresponsetothe
surfaceoftheovaryleadstoadhesion
formation

32. •Therecurrentsheddingoftheendometriosis
withintheovarianinvaginationleadstocystic
formationwithmenstrualbloodcollecting
overaperiodoftime,therebyleadingto
increasingchocolatecystformation.

34. RECTOVAGINAL ENDOMETRIOSIS
•Thisformofthediseaseoccursbetweentherectum
andthevagina,andhasadifferenthistological
appearance.
•Theserectovaginalnodulesmayariseseparatelyand
throughadifferentprocess;asthepresenceofmuscle
cellsalmostrequiresadifferentorigin.

35. CLINICALMANIFESTATIONS
•Seen in age between30-40
•Usuallyasymptomatic
•Symptoms not related to extend of lesion,
sometimes minimal endometriosis can result
in intensesymptoms

36. •Depth of penetration is more related to
symptoms rather than the spread.
•Lesions penetrating more than 5 mm are
responsible for pain, dysmenorrhoea and
dyspareunia.
•Powder burns lesions produce more
prostaglandin F and hence more painful.

37. •Dysmenorrhoea(50%)
•Abnormalmenstruation(60%)
•Infertility(40-60%)
•Dyspareunia:
•Chronic pelvicpain

38. •Othersymptoms
•Bladder: frequency, dysuria, or even
hematuria
•Sigmoid colon and rectum: painful
defecation (dyschezia), diarrhea, rectal
bleeding or even malena.
•Perimenstrualsymptoms(bowel and
bladder).

39. •Abdominalexamination
•Amassmaybefeltinthelowerabdomen
arisingfromthepelvis-enlargedchocolate
cystortuboovarianmassdueto
endometrioticadhesions.Themassistender
withtherestricedmobility.

40. •Pelvicexamination
•pelvictenderness,nodulesinthepouchof
Douglas,nodularfeeloftheuterosacral
ligaments,fixedretroverteduterusor
unilateralorbilateraladnexalmassvarying
sizes.
•Speculumexaminationmayrevealbluishspots
intheposteriorfornix
•Rectalorrectovaginalexaminationisoften
helpfultoconfirmthefindings.

41. DIAGNOSIS
•Thisiscorroboratedbythepelvicfindingsof
nodulesfeeloftheuterosacralligaments,fixed
retroverteduterusandunilateralorbilateral
adnexalmass.

42. •Serum marker CA125
moderate elevation with severeendometriosis
•USG
Transvaginalsonographycan detect
ovarian endometriomas.
Transvaginal and endorectal ultrasound are
found better for rectosigmoidendometriosis
•CT &MRI

43. •Laproscopy
powder burns or match stick spots onthe
peritoneum of thePOD.
•Biopsy
Confirmation of the exicised lesion is idealbut
negative histology does not excludeit.

44. STAGING

45. COMPLICATIONS
•Endocrinopathy
•Rupture of chocolatecyst
•Infection of the chocolatecyst
•Obstructivefeatures
–Intestinalobstruction
–Ureteralobstruction
•Malignancy israre

46. MANAGEMENT
PREVENTIVE:
•Toavoidtubalpregnancytestimmediatelyaftercurettageor
aroundthetimeofmenstruation
•Forciblepelvicexaminationshouldnotbedoneduringor
shortlyaftermenstruation
•Marriedwomanwithfamilyhistoryofendomentriosisare
encouragednottodelaythefristconceptionbuttocomplete
thefamily.

47. •ObservationwithadministrationofNSAIDSor
prostaglandinsynthetaseinhibitingdrugsareusedto
relievepain.Ibuprofen800-1200mgormefanamic
acid150-600mgadayisquiteeffective.
•Themarriedwomenareencouragedtohave
conception.Pregnancyusuallycuresthecondition.
CURATIVE

48. MEDICALTREATMENT
•Hormonaltreatment
•endometrial atropy is either by producing
pseudopregnancy (combined oral pills) orby
pseodomenopause( Danazol) or by medical
oopherectomy(GnRHanalogues).

49. Combinedestrogenandprogestogen
•Thelowdosecontrecptivepillsmaybe
prescribedeitherinacyclicorcontinuous
fashionwithadvantagesinyoungpatients
withmild
pregnancy.
disease
It
whowanttodefer
causesendometrial
decidualization andatropy.

50. •Progestogens
•It causes decidualization of endometrium
and atropy. High doses may suppress
ovulation and induce amenorrhoea. Oral
route is commonly used. Progesterone
antagonists, Mifepristone 50-100 mg/day
has laos found to beeffective.

51. •Danazol
•Itisstartedfromtheday5ofthemenstrual
cycle.Thedose600-800mgdailyisvariable
anddependsupontheextentofthelesion.

52. •GnRHanalogues
•When used continuously act as medical
oopherectomy,a state of hypooestrinismand
amenorrhoea.

53. SURGICALMANAGEMENT
INDICATIONS:
•Endometriosis with severesymptoms
unresponsiveto hormonetherapy.
•Severe and deeply infiltrating endometriosis
to correct the distortion of pelvicanatomy.
•Endometriomas of more than1cm

54. CONSERVATIVE SURGERY
•Laproscopy
•electrodiatherapy or by lazervapourization
•Laproscopic uterosacral nerveablation
(LUNA)

55. DEFINITIVESURGERY:
It isindicated
•No prospect for fertilityimprovement
•Other forms of the treatment havefailed
•Woman with completedfamily.
•Hysterectomy with bilateralsalpingo-
oophorectomy

56. COMBINEDMEDICALANDSURGICAL:
Pre-operativehormonaltherapyaimsat
reductionofthesizeandvascularityofthe
lesionwhichfacilitatesurgery.

57. NURSING MANAGEMENT
•The health history and physical examination focus on
specific symptoms (eg. Pain) and when and how long they
have been bothersome, the effect of prescribed
medications and the women’s reproductive plans.
•This information helps in determining the treatment plan.
•Explaining the various diagnostic procedures may help to
alleviate the patients anxiety.
•The main goal includes relief of pain, dysmenorrhea,
dyspareunia, avoidance of infertility.

58. •As the treatment progress, the woman with
endometriosis and her partner may find that pregnancy is
not easily possible and the psychosocial impact of this
realization must be recognized and addressed.
•The nurse’s role in patient education is to dispel myths
and encourage the patient to seek care if dysmenorrhea
or dyspareunia occurs.
•The endometriosis association is a helpful resource for
patients seeking further information and support for this
condition, which can cause disabling pain and severe
emotional distress.