Endometriosis

1. Endometriosis
ENDOMETRIOSIS

2. •Is characterized by the presence of
endometrial tissue on the ovaries, fallopia
n tubes or other sites, causing pain or infe
rtility.
•The disease tends to progress under the
repetitive influence of the menstrual cycle I

3. •Dense adhesions are commonly associated with
advanced endometriosis.
•They can be treated with laparoscopy techniques, but
are more likely to reform after surgery.

4. •Minimal adhesions between the left ovary and
pelvic sidewall.
•Commonly associated with mild to moderate
endometriosis.

6. Ovary with endometrioma.

7. •This picture shows a chocolate cyst, which can be quite
common in more advanced endometriosis

8. Rupture endometrioma

9. Endometriosis!
•Epidemiology
–> 70 million women and girls have
Endometriosis world-wide.
–10 - 20 % of women of reproductive age have
Endometriosis.
–It is more common than breast cancer or Aids,
and many other diseases, that are well known
•Endometriosis is not usually fatal

10. •the longer that this disease
goes undiagnosed
• the more damage it can do.

11. Pathogenesis
• is not well understood
•is probably multifactorial
in origin
•the most widely
embraced theory
involves retrograde
menstruation5
Retrograde menstruation

12. Investigation
•A definitive diagnosis can be made only by
means of laparoscopy
•Imaging tests: ultrasound, MRI, CT, are
occasionally used to identify individual
lesions
•Biochemical markers
–CA-125 A recent study of this antigen level,
showed it to be high in 90 percent of women
with Endometriosis

13. Stages of Endometriosis
•Based on the severity, location,
amount, depth and size of growths.
•The stages of the disease do not
indicate the level of pain, infertility or
symptoms.
•the correlation between stage and
extent of disease remains controversial

14. Stages of Endometriosis
Stage 1 - minimal disease, superficial
and filmy adhesions
Stage 2 - mild disease, superficial and
deep endometriosis
Stage 3 - moderate disease, deep
endometriosis and adhesions
Stage 4 - severe disease, deep
endometriosis, dense adhesion

15. Classification of
Endometriosis
(Modified American
Fertility Society System)•Base on extent of
peritoneum,ovary,tube,cul de sac
endometriosis and adhesions
–Stage IScore 1-5 minimal
–Stage IIScore 6-15 mild
–Stage IIIScore 16-40
moderate
–Stage IVScore > 40 Severe

16. Classification of
Endometriosis
168*4*
Dense
421L Filmy
168*4*
Dense
421R FilmyTube
1684
Dense
421L Filmy
1684
Dense
421R Filmy
>2/3enc
losure
1/3-2/3
enclosure
< 1/3
enclosure
Adhesi
ons
Ovar
y

17. Classification of
Endometriosis
20164 Deep
4
40
partial
complete
posterior cul
de sac
obliteration
20164 Deep
421L Superficial
421R SuperficialOvary
642Deep
421Superficial
>3cm1-3 cm<
1CM
Endometriosi
s
Periton
eum

18. Common site of endometriosis

19. Endometriosis Symptoms
•Endometriosis does
not follow any
distinct pattern
•The symptoms of
Endometriosis vary
from one woman to
another
•The most common
symptom is pelvic
pain.

20. The most common symptoms
•Pain before and during periods
•Pain with intercourse
•General, chronic pelvic pain throughout the month
•Heavy and/or irregular periods
•Painful urination during menstruation
•Infertility
•Fatigue
•Low back pain
•Painful bowel movements, especially during
menstruation
•Diarrhoea or constipation

21. Symptoms relate to endometriosis site
•Reproductive Endometriosis
–Pelvic pain
–Ectopic (tubal) pregnancy
–Dysmenorrhea
–Infertility
–Miscarriage(s)
–Painful ovulation
•Uterosacral/Presacral Nerve Endometriosis
–Backache
–Leg pain
–Dyspareunia
•Cul-de-sac ("Pouch of Douglas") Endometriosis
–Dyspareunia (pain during intercourse)
–Gastrointestinal symptoms
–Pain after intercourse

22. •Gastrointestinal symptoms of Endometriosis
–Nausea
–Diarrhea
–Blood in stool
–Bloating
–Vomiting
–Rectal pain
–Rectal bleeding
–Tailbone pain
–Abdominal cramping
–Constipation
–Sharp gas pains
–Painful bowel movements
Symptoms relate to endometriosis site

23. •Urinary tract Endometriosis
–Blood in urine
–Painful or burning urination
–Hypertension
–Tenderness around the kidneys
–Flank pain radiating toward the groin
–Urinary frequency, retention, or urgency
Symptoms relate to endometriosis site

24. •Pleural (lung & chest cavity) Endometriosis
–Very occasionally
–Coughing up of blood or bloody sputum, particularly
coinciding with menses
–Accumulation of air or gas in the chest cavity
–Constricting chest pain and/or shoulder pain
–Collection of blood and/or pulmonary nodule in chest
cavity (revealed under testing)
–Shortness of breath
Symptoms relate to endometriosis site

25. Symptoms relate to endometriosis site
•Skin Endometriosis
– Painful nodules, often visible to the naked
eye, at the skin's surface. Can bleed during
menses and/or appear blue upon
inspection.
•Sciatic Endometriosis
–Hip pain
–pain that radiates from the buttock and
down the leg

26. Differential diagnosis by symptoms
•Generalized pelvic pain
–Pelvic inflammatory disease
–Endometritis
–Sexual or physical abuse
–Neoplasms, benign or malignant
–Ovarian torsion
–Pelvic adhesion
–Nongynecologic causes

27. Differential diagnosis by symptoms
• Dysmenorrhea
–Primary
–Secondary (adenomyosis, myomas,
infection, cervical stenosis)

28. Differential diagnosis by symptoms
• Dyspareunia
–Musculoskeletal causes (pelvic relaxation,
levator spasm)
–Gastrointestinal tract (constipation,
irritable bowel syndrome)
–Urinary tract (urethral syndrome,
interstitial cystitis)
–Infection
–Pelvic vascular congestion

29. Differential diagnosis by symptoms
• Infertility
–Male factor
–Tubal disease (infection)
–Anovulation
–Cervical factors (mucus, sperm antibodies,
stenosis)
–Luteal phase deficiency

30. Treatment options for Endometriosis
There are general points which should be taken into
consideration
• The severity of the symptoms
• The type of symptoms
• The age of the patient
• The desire to get pregnant or not
• Length of treatment
• Coping with side-effects of drug treatment
• Cost

31. Treatment options
•Observation with no medical
intervention
•Hormone treatment
•Surgery
•Combined treatment

33. Drugs Commonly used
•GnRH agonists
–inhibit the secretion of gonadotropin a complete block of egg
development, estrogen production and menstrual cycle, makes
'menopausal'
•Danazol
–is a mild form of the male hormone testosterone inhibits
leuteinizing hormone (LH) and follicle-stimulating hormone (FSH
)
•Gestrinone
–It works in much the same way as danazol with similar, but
milder, side effects
•Contraceptive pill
–suppress LH and FSH and prevent ovulation
•Progestational Agents
–Depo-Provera
–Progesterone hormone tablets
•The Mirena Coil (IUD with Levonorgestrel )

34. GnRH agonists
Gonadotropin-releasing hormone agonist
•leuprolide (Lupron, Eligard)
•buserelin (Suprefact, Suprecor)
•nafarelin (Synarel)
•histrelin (Supprelin)
•goserelin (Zoladex)
•deslorelin (Suprelorin, Ovuplant)

35. GnRH antagonist
•Abarelix (Plenaxis)
•Cetrorelix (Cetrotide), by Serono
•Ganirelix (Antagon), by Organon
International

36. Surgery
•Definitive surgery, which includes
hysterectomy and oophorectomy, is reserv
ed for use in women with intractable pain
who no longer desire pregnancy.
•In less severe cases, one ovary may be
retained to preserve ovarian function

37. Surgical treatment

38. Surgical Treatment
Laparoscopic excision of nodular
endometrial lesions overlying the rectu
m
Nodular endometrial lesions in the
posterior cul-de-sac.

39. Surgical vs. Medical Treatment of
Endometriosis
Effective for pain relief
Unlikely to improve
fertility
Empiric treatment
Adverse effects
common
Decreased initial cost
Medical
Option for definitive treatment
Definitive diagnosis
InvasivePossibly better long-term results
ExpensiveBeneficial for infertility
Surgical
DisadvantagesAdvantages
Treatm
ent
•Adverse effects common
•Unlikely to improve fertility
•Decreased initial cost
•Empiric treatment
•Effective for pain relief
Medical
•Expensive
•Invasive
•Beneficial for infertility
•Possibly better long-term
results
•Definitive diagnosis
•Option for definitive treatment
Surgical
Disadvantages Advantages Treatment

40. Recurrence Rates
•a laparoscopically defined cumulative five-year
recurrence rate of about 19 percent.
•the long-term benefit of surgical intervention for
pain is enhanced by definitive surgery, including
bilateral oophorectomy, with a 10 percent cumul
ative recurrence after 10 years.
•surgical treatment is the apparently lower
recurrence rate compared with medical treatmen
t