Endometriosis د. نجمه محمود كلية الطب جامعة بغداد فرع النسائية والتوليد
Objectives:- To know what is endometriosis The sites where it occur To explain its itiology & pathogenesis To know the clinical features of this disease & how to diagnose & treat it To know the mechanism by which this disease cause infertility
Definition :- Endometriosis defined as presence of endometrial surface epithelium & or endometrial glands & stroma outside the uterine cavity.
Sites of endometriosis:- Ovaries. Fallopian tubes The back of the uterus Within the myometrium & called adenomyosis. broad ligament. Pelvic peritoneum Intestines, most commonly the rectosigmoid Urinary bladder and ureters. Vulva,vagina Lung Abdominal scars.
Ruptured left endometrioma of ovary
Endoscopic pcture of endometriotic spots in POD & uterosacral ligament.
Etiology &Pathogenesis:- 1. The implantation theory & menstrual regurgitation. 2. Coelomic metaplasia theory. 3. Lymphatic & vascular dissemination. 4. Genetic & immunological factors.
Pathogenesis:- Peritoneal endometriosis:- 1-Red endometriosis. 2- Black endometriosis. 3- White endometriosis. Ovarian endometriosis:- Endometrioma ( choclate cyst) Rectovaginal endometriosis.
Clinical features :- 1- Asymptomatic. 2- Pelvic pain chronic pelvic pain, congestive dysmenorrhea deep dyspareunia( painful intercourse, dysurea urinary urgency, frequency, and sometimes painful voiding, dyschesia 3- Infertility 4- Features of acute abdomen due to rupture or torsion of endometrioma 5- Menorrhagia & irregular menses.
6- Abdominal & pelvic mass. 7- Cyclic heamaturia, cyclic rectal bleeding. 8- Cyclical pain & bleeding from umbilicus or surgical scars. 9- Cyclical heamoptysis & heamopneumothorax if involve the lungs. 10- O/E fixed RV uterus with hard tender nodules, adnexial mass of endometrioma.
Investigations:- 1) Laprascopy:- it remain the goldstand means of diagnosing the condition it visualize # white thickening scar of endometriosis # fixed RV uterus # burn match stick appearance #adhesion # choclate cyst in the ovaries # heamatosalpinx # it allow take a biopsy from the lesion & give a benefit to determine the extent of the disease & staging, also it allow concurrent therapy at the time of laprascopy in the form of cautery or laser treatment in selected cases.
2) USS:- help in diagnosis of endommetrioma. 3) Ca125 level :- this is a glycoprotien expressed by some epithelial cells of coelomic origin it increase in cases of endometriosis.
4) MRI:- this can detect endometriosis in ovaries or bladder or bowel & rectovaginal septum.
Endometriosis & Infertility:- 30 40% of pt with endometriosis have infertility & about 15% of pt with infertility have endometriosis. Mechanism by which endometriosis cause infertility are :- 1) Ovarian function 2) Tubal function. 3) Coital function. 4) Sperm function. 5) Early pregnancy failure. 6) adhesions.
Treatment of endometriosis:- Medical treatment or surgical treatment 1) Medical treatment :- a) COC P. b) Danazole & gestrinone. c) Progestogens. d) LHRH analogue. e) NSAID.
Surgical treatme:nta) Conservative surgery by using laprascopy b) Radical surgery by TAH&BSO in old age pt &who complete her family, postoperative HRT can be used especially in young age women but it is preferred to delayed for 6 months or more to minimize the risk of recurrence.
Adenomyosis # Repeated pregnancy. # vigourous curretage. # endometrial hyperplasia. Pathology:- The uterus is symetrically enlarged, the lesion could be localized or diffused throught the uterine wall, cystic space filled with blood within myometrium on HP exam.
Clinical features:- *** Menorrhagia *** Secondary dysmenorrhea. *** Pelvic discomfort & dysparonia. *** O/E bulky symetrically enlarged tender uterus with regular outline. Diagnosis:- 1) USS 2) MRI 3) Biopsy & HP exam.
Treatment:- 1) Medical treatment as danazole, gestrinone, GnRH agonist as for endometriosis. 2) surgical treatment:- hysterectomy.