ENDOMETRIOSIS A QUICK REVISE FOR MEDICOS.pptx

Endometriosis — Rapid Revision for Clinicians
A sharp, bullet-driven review of endometriosis: definition, staging, clinical presentation, diagnostic criteria (imaging + laparoscopy), treatment algorithm, and pitfalls to watch out for.

1. Endometriosis A Quick Revise Dr Sagar D Dherange MS OBGYN - A

2. Endometriosis Defination - Presence of functioning endometrium (glands & stroma ) in sites other than uterine mucosa is called endometriosis

3. Sites of endometriosis 1 ) Common ovaries, pelvic peritoneum, Pouch of douglas Uterosacral ligament, Rectovaginal septum, sigmoid colon, appendix, Pelvic lymph node, Fallopian Tubes 2) Rare – Umbilicus, Abdominal scar, Episiotomy scar , Lungs, Pleura, ureter, Kidney, Arms , Legs, nasal mucosa  

4. Theories for Pathogenesis of Endometriosis 1 ) Retrograde Menstruation (Sampson Theory) 2) Coelomic Metaplasia (Meyer & Ivanoff ) 3) Direct Implantation 4) Lymphatic ( Halban ) 5) Vascular 6) Genetic & Immunologic Factors 7) Environmental Theory

5. Risk Factors 1 ) Nulliparous 2) Outflow obstruction 3) Family history of endometriosis  

6. Pathological Changes 1 ) Lesion shows proliferative changes with absent secretory changes. 2) Lesion sheds blood periodically followed by dense tissue reaction leading to adhesion & puckering of peritoneum 3) Encysted cyst, enlarged with periodical cyclic bleeding forming chocolate cyst (Absorption of serum →chocolate colour ). 4) Falloplian Tubes remains patent 5) Powder burn appearance on utero sacral ligament & pouch of douglas -Pelvic endometriosis  

7. Clinical features- 1 ) Dysmenorrhoea - Gradual increasing secondary dysmenorrhoea 2) Abnormal Menstruation-Menorrhagia , Polymenorrhoea , Epimenorrhoea 3) Infertility 4) Dysparesuia 5) Chronic pelvic pain 6) Abdominal Pain 7) Urinary Dysuria, increased frequency, Haematuria 8) Bowel - Dyschezia (Painful defecation) , Constipation, diarrhorea , malena 9) Fatigue 10) Peridic bleeding from surgical scar, haemoptysis (rarely)

8. Examination 1 ) P/A- No any palpable pathology 2) P/V- Nodules in pouch of douglas ‘Cobblestone feel’ Nodular feel of utero sacral ligament fixed Retroverted Uterus Unilateral / Bilateral adnexal mass 3) P/S- Bluish spots in posterior fornix 3) P/R- Tenderness at pouch of Douglas

9. Diagnosis 1 ) Laproscopy Gold Standard. Others 1) USG 2) MRI 3) Ca 125- Not Specific for endometriosis

10. Grading (on basis of AFS) 1 ) Stage I (Minimal) – 1-5 2) Stage II (Mild) – 6-15 3) Stage III (Moderate) - 16-40 4) Stage IV (severe) - >40

11. Endometriosis Stage Manifestation of the Condition Stage I (1-5 points) Minimal Few superficial implants Stage II (6-15 points) Mild More and deeper implants Stage III (16-40 points) Moderate Many deep implants Small cysts on one or both ovaries Presence of filmy adhesions Stage IV (>40 points) Severe Many deep implants Large cysts on one or both ovaries Many dense adhesions

12. Endofound Endometriosis Classification Category I : Peritoneal endometriosis The most minimal form of endometriosis in which the peritoneum, the membrane that lines the abdomen, is infiltrated with endometriosis tissue . Category II : Ovarian Endometriomas (Chocolate Cysts) Endometriosis that is already established within the ovaries. These forms of ovarian cysts are of particular concern due to their risk of breaking and spreading endometriosis within the pelvic cavity . Category III : Deep Infiltrating Endometriosis I (DIE I) The first form of deep infiltrating endometriosis involves organs within the pelvic cavity. This can include the ovaries, rectum, uterus, and can significantly distort the anatomy of the pelvic organs . Category IV : Deep Infiltrating Endometriosis II (DIE II) The other more extreme form of DIE involves organs both within and outside the pelvic cavity. This can include the bowels, appendix, diaphragm, heart and lungs among others .

13. Complications 1 ) Endocrinopathy - Luteal Phase Defect, Luteinized Unruptured Follicle, Anovulation, Double LH peak, Prolactinemia 2) Rupture of chocolate cyst 3) Infection of chocolate cyst 4) Obstruction to intestines, ureter 5) Malignancy- Rare

14. Management Prevention 1) Avoid HSG just after menses or curettage 2) Avoid P/V examination during or just after menses. 3) Avoid Sexual act during menses 4) Encourage early first conception

15. Treatment 1 ) Drugs – line of management a) Hormones Pseudopregnancy Pseudomenopause medical oopherectomy b) Others Analgesics

16. 2) Surgical Conservative Laproscopic Adhesiolysis Laproscopic Uterine Nerve Ablation Aspiration of endometrioma b) Definative Excision of endomerioma Hysterectomy with bilateral salphingo oopherectomy Scar excision , excision of local tissue

17. Management depends upon following factors 1 ) Age 2) Marital Status 3) Desire for pregnancy 4) Clinical Stageing

18. a) Pseudopregnancy 1 ) Combined OCP for 6 to 9 months. ( Ovaral L, Loette ) 2) Tab Medroxy Progesterone Acetate ( Deviry ) 10 mg TDS x 6-9 month 3) Tab Dydrogesterone ( Duphastone ) 10mg OD/BD X 6-9 month 4) Tab Norethisterone ( Crina NCR) 10mg OD/BD/TDS x 6-9 months 5) Inj Depot Medroxy Progesteron Acetate ( Antara ) 150 mg IM every 3 months. 6) LNG-IUS ( Mirena , Emily)

19. b) Pseudomenopause 1 ) Danazol ( Danogen ) 400-800mg daily x 6-9 months. 2) Gestrionone ( Nemestran ) 1.25mg OD/BD x 6-9 months.

20. c) Medical oopherectomy 1 ) Leuprolide ( Inj Leupride ) 3.75 mg IM monthly x 6 month 2) Triptorelin ( Inj Decapeptyl ) 3.75 mg IM Monthly x 6 months  

21. d) Aromatase Inhibitors 1 ) Leutrozole ( Letroz ) 2.5 mg OD/BD x 6-9 months 2) Anastrozole ( Altraz ) 1mg OD/BD x 6-9 month.  

22. e) Progesterone Antagonist Mifepristone 50-100 mg/day.

23. Thank You…