sgh, endometriosis, lectures

1. Endometriosis
By: Tan Hong Yang
Pang Ing Xiang

2. What is endometriosis?
• Endometriosis is defined as the presence of
endometrial-like tissue outside the uterus,
which induces a chronic, inflammatory
reaction. The condition is predominantly
found in women of reproductive age,
from all ethnic and social groups

3. Endometriosis - Symptoms
• ● severe dysmenorrhoea
• ● deep dyspareunia
• ● chronic pelvic pain
• ● ovulation pain
• ● cyclical or perimenstrual symptoms, such as bowel or
bladder, with or without abnormal bleeding or
• pain
• ● infertility
• ● chronic fatigue
• ● dyschezia (pain on defaecation).

4. Localisation and appearance of
endometriosis
• pelvic organs and peritoneum, although other parts of the
body such as the bowel or lungs are occasionally affected.
• ‘powder-burn’ or ‘gunshot’ lesions on the ovaries, serosal
surfaces and peritoneum: black, dark-brown or bluish
puckered lesions, nodules or small cysts containing old
haemorrhage surrounded by a variable extent of fibrosis

5. • Atypical or ‘subtle’ lesions are also common,
• including red implants (petechial, vesicular,
polypoid, hemorrhagic, red flame-like) and serous
or clear vesicles. Other appearances include white
plaques or scarring and yellow-brown peritoneal
discoloration of the peritoneum.

6. Localisation of endometriosis

7. Endometriosis

8. Surgically, endometriosis can be
staged I–IV (Revised
Classification of the American
Society
• Stage I (Minimal) Findings restricted to
only superficial lesions and possibly a few
filmy adhesion
• Stage II (Mild) In addition, some deep
lesions are present in the cul de sac

9. • Stage III (Moderate) As above, plus
presence of endometriomas on the ovary
and more adhesions.
• Stage IV (Severe) As above, plus large
endometriomas, extensive adhesions.
Endometrioma on the ovary of any
significant size (Approx. 2 cm +) must be
removed surgically because hormonal
treatment alone will not remove the full
endometrioma cyst, which can progress to
acute pain from the rupturing of the cyst
and internal bleeding

10. Classification of Endometriosis
Stage I (Minimal) Stage II (Mild)
4* 9
Stage III (Moderate) Stage IV (Severe)
29 114
* Revised AFS Score

11. Endometriosis – Physical Exam
• Uterosacral nodularity
• Adnexal mass (endometrioma)
• Normal exam

12. Endometriosis - Incidence
• 7-10% of general population
• 20-50% of infertile women
• 70-85% in women w/ CPP
• No racial predisposition
• +Familial association with almost 10x
increased risk of endometriosis if affected 1 st
degree relative

13. Endometriosis - Pathogenesis
• Retrograde menstruation (Sampson)
• Hematogenous or lymphatic spread
(Halban)
• Coelomic metaplasia (Meyer/Novack)
• Iatrogenic dissemination
• Immunologic defects (Dmowski)
• Genetic predisposition

14. Endometriosis - Pathogenesis
• Retrograde menstruation (Sampson’s theory)
- Monkey experiments – sutured cervix closed to
create outflow obstruction  caused development
of endometriosis
- Clinical observation of retrograde menstrual flow
during laparoscopy in humans
- Increased risk of endometriosis in women with
cervical/vaginal atresia, other outflow obstruction
- Increased risk with early menarche, longer and
heavier flow
- Decreased risk with decreased estrogen levels
e.g. exercise-induced menstrual disorders,
decreased body fat, + tobacco use

15. Endometriosis - Pathogenesis
• Hematogenous or lymphatic spread
- Endometriosis found in remote sites – lung, nose,
spinal cord, pelvic lymph nodes.

16. Endometriosis - Pathogenesis
• Coelomic metaplasia
- Mullerian ducts are derived from coelomic
epithelium during fetal development
- Hypothesize that coelomic epithelium retains
ability for multipotential development
- Endometriosis seen in prepubertal girls, women
w/ congenital absence of the uterus, and RARELY
in men

17. Endometriosis - Pathogenesis
• Iatrogenic dissemination
- Endometriosis has been found in cesarean
section scar
• Immunologic defects
• Genetic predisposition
- polygenic, multi-factorial

18. Endometriosis - Diagnosis
• For a definitive diagnosis of endometriosis,
visual inspection of the pelvis at laparoscopy is
the gold standard investigation, unless disease
is visible in the posterior vaginal fornix or
elsewhere
• Good surgical practice is to use an instrument
such as a grasper, via a secondary port, to
mobilise the pelvic organs and to palpate
lesions, which can help determine their
nodularity

19. Endometriosis - Diagnosis
• Laparoscopy with biopsy proven histologic
diagnosis – standard for dx of endometriosis
- Extent of visible lesions do not correlate with
severity of sx, but depth of infiltration of lesions
seems to correlate best with pain severity

20. • Laparoscopy with biopsy proven histologic
diagnosis – standard for dx of endometriosis
• Positive histology confirms the diagnosis of
endometriosis; negative histology does not
exclude it
• Empiric medical treatment with improvement in
symptoms
• CA 125 – NOT considered to be of clinical utility
• Imaging – US, MRI, CT – only useful in the
presence of pelvic or adnexal masses
(endometriomas)

21. Endometrioma

22. Ultrasound of Endometrioma
on US, endometriomas appear as
cysts that contain low-level
homogeneous internal echoes
consistent with old blood (ddx
includes hemorrhagic cysts)

23. MR of Endometrioma

24. Endometriosis - Diagnosis
2 or more of the following histologic features are criteria for Dx:
1. Endometrial epithelium
2. Endometrial glands
3. Endometrial stroma
4. Hemosiderin-laden macrophages

25. Endometriosis - Treatment
• Hormonal Medications
1 Combination oral contraceptive pills
2 Progestational agents
3 Gonadotropin-releasing hormone analogues
4 Danazol

26. Medical Treatment
Progestin
Ovary Estrogen
Endometriosis
Oral contraceptives Tissue
Danazol
GnRH agonists

27. COCP
• COCPs act by ovarian suppression and continuous progestin
administration. Initially, a trial of continuous or cyclic
• Continuous noncyclical administration of COCPs, omitting
the placebo menstrual tablets, for 3-4 months helps avoid
any menstruation and associated pain.
• Women with endometriosis are at increased risk of
epithelial ovarian cancer, and COCPs are believed to protect
against this.
• Eg: MARVELON

28. Progestational agents
• All progestational agents act by decidualization and atrophy
of the endometrium.
• Medroxyprogesterone acetate has proven efficacy in pain
suppression in both the oral and injectable depot
preparations. Oral doses of 10-20 mg/d can be administered
continuously. The time to resumption of ovulation is longer
and variable with depot preparations. Adverse effects
include weight gain, fluid retention, depression, and
breakthrough bleeding.
• The levonorgestrel intrauterine system (LNG-IUS) has been
shown to reduce endometriosis-associated pain. It has been
found to reduce the recurrence of dysmenorrhea by 35%

29. Danazol
• Danazol acts by inhibiting the midcycle
follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) surges and
preventing steroidogenesis in the corpus
luteum. It is the most extensively studied
agent for endometriosis.
• The recommended dose is 600-800 mg/d.
However, smaller doses have been used
with success.

30. GnRH Analogs
• GnRH analogues produce a hypogonadotrophic-
hypogonadic state by downregulation of the pituitary
gland. Ie Leucrin ( 3.75mg monthy or 11.25mg 3 monthly)
• GnRH therapy may lead to improvement in pain associated
with endometriosis in 85-100% of women. Furthermore,
the pain relief is believed to persist for 6-12 months after
cessation of treatment.
Treatment is usually restricted to monthly injections for 6
months. Loss of trabecular bone density caused by GnRH
is restored by 2 years after cessation of therapy .Other
prominent adverse effects include hot flashes and vaginal
dryness

31. • Add-back therapy
GnRH agonist treatment with GnRH agonist plus ‘add-
back’ therapy (i.e. tibolone) for at least 6 months, bone
mineral density was significantly
• How long a GnRH agonist plus ‘add-back’ may safely be
continued is unclear, but treatment for
• up to 12 months with ‘add-back’ appears to be effective
• and safe in terms of pain relief and bone mineral density
protection.
• consideration should be given to the use of GnRH agonists
in women who may not have reached their maximum bone
density.

32. Endometriosis – Treatment
Considerations in Adolescents
• If no improvement in symptoms after 3
months of empiric treatment with NSAIDs
and OCPs, diagnostic laparoscopy should
be offered

33. Endometriosis - SURGERY
• Surgical care can be broadly classified as
1)conservative- preserve reproductive
ability
• 2)semiconservative- when reproductive
ability is eliminated but ovarian function is
retained
• 3) Radical- when the uterus and ovaries are
removed

34. Conservative surgery
Aim- destroy visible endometriotic implants
and lyse peritubal and periovarian
adhesions that are a source of pain and may
interfere with ovum transport.
-laparoscopic drainage
-laparoscopic cystectomy
-laparoscopic ablation
-LUNA
-presacral neurectomy

35. Semiconservative Surgery
• The indication for this semiconservative
surgery is mainly in women who have
completed their childbearing, are too young
to undergo surgical menopause, and are
debilitated by the symptoms.
• Such surgery involves hysterectomy and
cytoreduction of pelvic endometriosis

36. Radical Surgery
• Radical surgery involves total hysterectomy
with bilateral oophorectomy (TAH-BSO)
and cytoreduction of visible endometriosis.
Adhesiolysis is performed to restore
mobility and normal intrapelvic organ
relationships

37. Endometriosis - Treatment
• Medications vs. Surgery
- Lack of data to support surgery vs. medical
treatment for tx of pain symptoms due to
endometriosis
- Starting with empiric medical therapy is
appropriate
- Offer GnRH agonist therapy if initial medical
treatment with OCPs and NSAIDs not helping
- Cost of comparing empiric medical management
with definitive surgical diagnosis is difficult to
assess, but 3 months of empiric treatment is less
than a laparoscopic procedure

38. Endometriosis - Treatment
• Medications vs. Surgery
- Surgery is associated with significant
decrease in pain sx during the 1st 6 months
following surgery
- Approximately 40% experience recurrent
symptoms within 1 yr post-op
- Cumulative 5-yr recurrence rate of pain sx
after d/c GnRH tx is ~50%