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Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & HospitalMahatma Gandhi Medical College, Jaipur.
Presence of active functioning endometrial implants outside its normal place i.e uterine cavity Incidence:20-25% in reproductive age group
Implantation theory :Sampsons pioneering work in 1922 attributed endometriosisto reflux of menstrual endometrium through the fallopiantubes. Occurrence of scar endometriosis following classicalcaesarean section, hysterotomy, myomectomy and episiotomyfurther supports this view.Coelomic metaplasia theory :Meyer and Ivanoff (1919) propounded that endometriosisarises as a result of metaplastic changes in embryonic cellrests of embryonic mesothelium. Hormonal stimulation ofEmbryologically similar tissues to the Mullerian ducts. Metastatic theory :Suggested by Halban et al. (1924) that embolization ofmenstrual fragments through vascular or lymphaticchannels, explain its occurrence at less accessible siteslike the umbilicus, pelvic lymph nodes, ureter,rectovaginal septum, bowel wall, and remote sites likethe lung, pleura, endocardium and the extremities.
Hormonal influence : The initial genesis ofendometriosis, its further development depends on thepresence of hormones, mainly oestrogen. Pregnancycauses atrophy of endometriosis through highprogesterone level. Regression also follows oophorectomyand irradiation. Endometriosis is rarely seen beforepuberty and it regresses after menopause. Hormones withantioestrogenic activity also suppress endometriosis andare used therapeutically.Immunological factor : The peritoneal fluid inendometriosis shows the presence of macrophages andnatural killer (NK) cells. Impaired T cell and NK cell activityand altered immunology.Other factors : Genetic - familial tendency reported in15% cases, multifactorial, vaginal or cervical atresia whichencourage retrograde spill. Prostaglandins.
- Pelvic- Extra pelvicUmbilicus.Scars (Lap.).Lungs & pleura.Others.
Early lesions appear papular and red vesicles are filled withhaemorrhagic fluid with surrounding flame-like lesions.Over time, these vesicles change colour and endometrioticareas appear as dark red, bluish or black cystic areasadherent to the site. Scarring in the endometriosis makes itpuckered. Atypical lesions such as non-pigmented areas oryellowish-white thick plaques have been noticed, which arehealed lesions. Powder burnt areas are the inactive and oldlesions seen scattered over the pelvic peritoneum.Chocolate cysts of the ovaries represent the most importantmanifestation of endometriosis. To the naked eye, thechocolate cyst shows obvious thickening of tunica albuginea,and vascular red adhesions are well marked on theundersurface of the ovary. The inner surface of the cyst wallis vascular and contains areas of dark brown tissue. Thechocolate cyst lies in the ovary and adherent to lateral pelvicwall.
On HistoryCommon symptoms : Chronic pelvic pain, worsening dysmenorrhea,acquired dyspareunia, infertility, premenstrualspotting, dyschezia.Risk factors : First degree relative affected, short menstrualcycles, long duration of menstrual flow, low parity,infertility, fair complexioned, reproductive tract
Examination On bimanual pelvic examination, fixed retroverted uterus,bilateral pelvic tenderness, fixed or enlarged ovaries and painfuluterosacral nodularity. Deeply infiltrating nodules are most reliably detected whenclinical examination is performed during menstruation.Adenomyotic uterus is seldom > 12 weeks, soft, smooth & tenderin contrast to fibroid uterus. Isolated adenomyoma can bedifferentiated by presence of localised tenderness
Investigations Laparoscopy: Gold standard It should not be performed within 3 months of hormonal treatment to prevent under diagnosis Ultrasound: Ultrasound has a limited role, however the addition of colour doppler claims to increase the sensitivity to 91.8%, specificity of 91.3% MRI –useful Ca 125-Maybe elevated in severe
Histological Confirmation: Visual inspection is usually adequate buthistological confirmation of at least one lesion isideal. In cases of ovarian endometrioma >3 cm indiameter and in deeply infiltrating disease,histology is a must to rule out malignancy.
Laparoscopy (Sensitivity : 97%, Specificity 95%)Types of lesions on laparoscopy:Powder burn or black lesionsWhite opacified peritoneumGlandular excrescencesFlame like red lesionsPeritoneal pockets or windowsClear vesiclesYellow brown patchesUnexplained adherence of ovary to peritoneum of ovarian fossaEncysted collection of thick chocolate coloured or tarry fluidsAdhesions to posterior lip of broad ligaments/other
LAPROSCOPIC IMAGES :A OLD ENDOMETRIOSIS (Blue/Grey) B OLD ENDOMETRIOSIS (Red)C OLD ENDOMETRIOSIS (Brown) D ACTIVE ENDOMETRIOSIS (Black)
Sonographic Features :Endometritic cysts (oval or round)- capsulated, fine homogeneous, uniform, granular echoes, anechoic, single or multiple, unilateral or bilateralOn Doppler: no vascularity within the massOvarian adhesions to uterusFree floating fimbria on sonosalpingography
Several Proposed Schemes Revised AFS System: Most Often Used Ranges from Stage I (Minimal) to Stage IV (Severe) Staging Involves Location and Depth of Disease, Extent of Adhesions
Revised American Fertility Society Classification of endometriosis 1985 Patients name Age Date Stage I (Minimal) Score 1-5 Laparoscopy/Laparotomy/Photography Stage II (Mild) Score 6-15 Recommended treatment Stage III (Moderate) Score 16-40 Stage IV (Severe) Score > 40 Total PrognosisPeritoneal endometriosis <1 cm 1-3 cm >3 cm Superficial 1 2 4 Deep 2 4 6Ovarian endometriosis <1 cm 1-3 cm >3 cm Right/Left side separate points Superficial 1 2 4 Deep 4 16 20cul-de-sac obliteration Partial Complete 4 40Ovarian adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left sideseparate points Flimsy 1 2 4 Dense 4 8 16 Tubal adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left sideseparate points Flimsy 1 2 4 Dense 4 8 16
Recognize Goals: – Pain Management – Preservation / Restoration of Fertility Discuss with Patient: – Disease may be Chronic and Not Curable – Optimal Treatment Unproven or Nonexistent
Management of Endometriosis must be ‘tailor made’ taking into account, patients profile, presenting symptoms, impact of the disease and effects of treatment on day to day life.
Empirical treatment of pain symptoms without definitive diagnosis of endometriosis, a therapeutic trial of hormonal drug to reduce menstrual flow is appropriate. Medical Therapy for endometriosis can be used either as primary therapy or in conjunction with surgery preoperatively or postoperatively- Sandwich Therapy
How effective are NSAIDS in treating endometriosis associated pain?There is inconclusive evidence to show whether NSAIDS are effective in managing pain caused by endometriosisAdvantages:Not operator dependentLess expensiveNo surgical/anesthetic riskNo post- op adhesion formationDisadvantages:Prolonged treatmentGastric ulcerationTemporary relief
• GnRH analogues: creates a pseudo menopausal state• Advantages:• Reduction in pelvic vascularity and inflammation• Reduction in size and activity of endometriotic implants• Reduction in ovarian cyst diameter• Reduction in cyst wall diameter• Disadvantages:• Hypoestrogenic state• Bone loss(can be controlled by add back regimen-
Progesterone:- Pseudo pregnancy (Kristner’s Regime) state.Acts by decidualisation and atrophy of the estrogen dependent endometriotic fociCommon progesterones : Medroxy progesterone acetate, norethesiterone, dydrogesterone,DMPA - cost effective, readily available, 66% complete resolutionLNG-IUS(Mirena) reduces endometriosis associated pain(symptom control over 3 years)Side effects : Irregular Bleeding, weight gain, fluid retention, breast tenderness, mood changes,
Gestrinone: Androgenic, progestogenic and antiestrogenic Dosage: 1-25-2-5mg biweekly Side effects : similar to danazol
Combined OC Pills: To reduce the frequent prolonged bleeding not recommended in infertile endometriotic women. However COCs are the only effective prophylaxis in against endometriosis.
RU 486: antiprogestogenic activity with minimal or no other endocrinologic effects Aromatase Inhibitor: Acts on the diseased endometriotic implants to decrease local oestrogen production-to inhibit the growth of implants. Interferons: combination with GnRH have resulted in higher cumulative pregnancy rates and monthly fecundity rates SERMs: Selective antiestrogenic activity on the endometrium, agonist activity on bones and
1997; Rice, 2002; Valle et al., 2003; Donnez et al., 2004; Crosignani et al., 2005; Schlaff et al., in press)Agent Dose Route Dosing frequency Common side effectsCombined 30–35 μg Oral Daily (cyclic or continuous) Irregular bleeding,oral ethinyl weight gain, bloating,contraceptives estradiol, breast tension and plus headache progestinDanazol 400–800 Oral Daily (duration limited to Androgenic/anabolic mg 6 months by side effects) (weight gain, fluid retention, breast atrophy, acne, oily skin, hot flashes and hirsutism)GnRH (Duration limited to 6agonists months due to BMD effects)Leuprolide 1mg/day SC daily Hypoestrogenic (hot injection flashes, vaginal dryness, emotional lability, loss of libido and BMD decline)Leuprolide 3.75mg IM Monthlydepot 11.75mg IM Every 3 monthly
Agent Dose Route Dosing frequency Common side effectsTriptorelin 3mg IM MonthlyTriptorelin 11.25mg IM Every 3 monthlydepotGoserelin 3.6mg SC MonthlyBuserelin 300- Intranasal Tds 400µgNaserelin 200- Intranasal Bd 400µgProgestins Irregular bleeding bloating weight gain and edemaDydrogestero 60mg Oral 12 days per cycleneGestrinone 2.5-5mg Oral DailyMegestrel 40mg Oral DailyacetateNorethindrone 5mg Oral DailyacetateMPA 30mg Oral dailyDMPA-150 150mg IM Every 3 months
Indications:Mild Endometriosis associated with infertilityEndometrioma >4 cm in diameterEndometriosis of rectovaginal septum or rectal wallFailed Medical therapyIntolerable side effects of medical therapyEndometriosis with other surgically correctable infertility factors
Pre operative assessment: MRI or Ultrasound with or without IVP, Barium enema, sigmoidoscopy Preoperative and post-op medical management: GnRh-a like goserilin for 3 months preoperatively reduces the size and AFS score. Postoperative therapy gives longer period of remission.
Primary operation is the best opportunity Best outcome by excision of the lesion Complete excision has lowest recurrence of 19% Adhesions require excision rather than simple division
Electrosurgical instruments are used for excision of endometriotic focii pelvic peritoneum, however the depth of dissection is unpredictable & hence damage to gut.Sophisticated energy sources available are:1. Carbon dioxide or Nd YAG laser: Allows vaporisation; excision; high cost2. Harmonic scalpel: Ultrasound mechanical source, for cutting and coagulation3. Argon beam: for widespread superficial lesion4. Helica thermal coagulator: effective in vaporisation with risk of thermal damage.
Surgery when pain relief is the priority: Early stage disease: LUNA along with ablation of endometrial deposits improves outcome Moderate to severe disease: Removal of the entire lesion recommendedEndometrioma:1. For large unilateral endometrioma- salpingoopherectomy of the affected side;2. Bilateral large endometrioma: <40years: ovarian tissue to be conserved as far as possible3. Insufficient evidence to justify use of pre op or post op hormones4. HRT recommendation after bilateral salpingooherectomy is controversial
Surgery when infertility is the priority Early stage disease: Laparoscopic excision or ablation with adhesiolysis Moderate to severe endometriosis: role of surgery is uncertain(overactive excision may reduce fertility) Endometrioma: laparosopic cystectomy better than drainage and coagulation.Post op hormonal treatment has no beneficial effect on pregnancy rates after surgeryTubal flushing improves pregnancy rates.
Treatment with IUI improves fertility in minimal to mild endometriosis IVF appropriate especially when tubal function is compromised, if there is male factor infertility and/or other treatments have failed. Treatment with GnRH agonists for 3-6months before IVF increases the rate of clinical pregnancies Laparoscopic ovarian cystectomy is recommended for endometriomas >4cm in diameter.