ENDOMETRIOSIS - GYNECOLOGY - EASYMEDNOTES 2021

 Endometriosis

Definition
Presence of endometrium in sites other than uterine mucosa is called endometriosis. or Endometriosis is a condition in which endometrial tissue is situated at sites other than the uterine cavity.

It is not a neoplastic condition, 
although malignant transformation is possible.


It is most commonly seen in the pouch of Douglas, ovaries,

 pelvic peritoneum, bladder, umbilicus and lungs.


Risk Factors

The major risk factors of endometriosis:

  • Early menarche
  • Family history of endometriosis in past
  • Short menstrual cycles
  • Prolonged and heavy menstrual bleeding
  • Any defects in the uterus or fallopian tubes


Common sites

The most common sites of the endometriosis are as follows:

  • Ovaries is the very common site
  • Lateral pelvic wall
  • Broad ligament
  • Pouch of Douglas
  • Uterosacral ligaments
  • Rectal wall
  • Sigmoid colon
  • Appendix
  • Pelvic lymph nodes
  • Fallopian tubes
  • pleura 
  • lungs
  • umbilicus


Pathology—General Considerations


  • The endometrium like tissue responds to the cyclical hormones.
  • This is estrogen produce proliferative phase and progesterone produce secretory phase.
  • Both these hormones form and then break down thus bleeding occurs.
  • This will happen over several cycles if there is no space for the blood to collect the serous part will absorb and convert it into dark thick liquid..
  • This region is surrounded by macrophages.
  • This thick liquid or fluid inside is very irritating and leads to fibrosis.
  • Ovary is the common site for  chocolate cyst.


DIAGNOSIS


  • Clinical diagnosis is by the classic symptoms of progressively increasing secondary dysmenorrhea, dyspareunia and infertility.
  • The physical examination has poor sensitivity and specificity. Many patients have no abnormal findings on examination.
  • Serum marker CA 125—A moderate elevation of serum CA 125 is seen in patients who are having severe endometriosis. 
  • It is not specific for endometriosis, as it is significantly raised in epithelial ovarian carcinoma. But, it is helpful in the therapeutic response and in the follow up of cases. and to detect any recurrence after therapy. 
  • Monocyte Chemotactic Protein (MCP-1) level is increased in the peritoneal fluid of women with endometriosis.

Imaging

  • Ultrasonography is not much helpful.
  • TVS can detect ovarian endometriomas. 
  • Transvaginal (TVS) and Endorectal ultrasound are found better for rectosigmoid endometriosis. 
  • Magnetic Resonance Imaging (MRI) is a diagnostic tool and it is useful for deep infiltrating endometriosis.
  • Colonoscopy, rectosigmoidoscopy and cystoscopy are done when respective organs are involved.
  • Laparoscopy is the gold standard diagnosis for endometriosis.
  • Confirmation of the case is done by double puncture laparoscopy or by laparotomy. 

Management

Medical management: 

  • Cyclical estrogen progesterone therapy
  • Pain suppressed through analgesics

Surgical management:

  • Laparoscopy


Complications of endometriosis


  • Endocrinopathy - This may be mostly responsible for infertility
  • Rupture of chocolate cyst
  • Infection of chocolate cyst
  • Obstructive features:

            -Intestinal obstruction

            -Ureteral obstruction 

  • Malignancy is rare, the commonest one being adenoacanthoma.

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