Classical Picture: Ms.

M came to your clinic, a nulliparous woman in her 30’s

complaining of infertility.
Persistence & spread are estrogen 10-15% women presenting
Pathogenesis Endometriosis Incidence
dependent, since it is found almost with gynecological symptoms
exclusively in female reproductive Definition
age group with functioning ovaries. One of the commonest benign gyn.
Presence of endometrial surface conditions
epithelium and/or the presence of Spasmodic, severe dysmenorhoea
Precise etiology unknown, but
unresponsive to analgesia is highly
interaction between one or more of endometrial glands & stroma
these theories occurs outside the lining of the uterine cavity Premenstrual and postmenstrual
spotting is characteristic
Menstrual regurgitation & Implantation
Subtypes symptom of endometriosis,
Coelomic epithelium transformation
Subtype Components Hormonal Response Laparoscopic
Genetic & Immunological factors
appearance
Vascular & lymphatic spread Free Surface Proliferative, secretory and Hemorrhagic
epithelium, menstrual changes vesicle/bleb
glands and
N.B. Minimization of menstrual flow stroma
& suppression of ovarian cycling  risk
Enclosed Glands and Proliferative, variable Papule and (later)
stroma Secretory change nodule
Symptoms No menstruation
Healed Glands only No response White nodule or
Site Symptoms
flattened fibrotic scar
Female Dysmenorrhea
reproductive Dyspareunia most Endometrio Variable (Post. Proliferative, secretory and Hemorrhagic
tract (ovaries, common Signs Investigations
broad Infertility
ligament, Lower abdominal &
uterosacral pelvic pain Vaginal Examination (occasionally CA 125 levels (less than ovarian cancer,
lig, post. Rupture/torsion none): useful in evaluation of Rx and recurrence)
cervix) endmetrioma  Thickening/nodularity “barbwire”
Low back pain of utereosacral ligaments Ultrasound (limited value, used to assess
(diagnostic). ovarian cyst for endometriomata –
Urinary tract Cyclic hematuria/dysuria  Tenderness in pouch of Douglas. homogenous, hypoechoic collection of low-
Ureteric obstruction  Ovarian mass or masses (2 out of level echoes within an ovarian cyst)
3).
GIT Dyschezia (triad D’s)
 Fixed retroverted uterus MRI (little benefit, better than US for
(rectovaginal Cyclic rectal bleeding
 DD also include PID, Ca. of uterus, ovarian cyst or invasion of surrounding
septum) Obstruction
ovary or cevix, hemorrhagic corpus
Surgical Cyclic pain and bleeding luteum, ectopic.). Laparoscopy (Gold Stand., Stag. & Rx)
Scars/umbilicus
N.B. There is no clear relationship between
Lung Rx
Cyclic hemoptysis the stage of endometriosis and the frequency
and severity of pain.
Medical Surgical (if > 3cm)
(aim to suppress estrogen and
progesterone levels to prevents
Adenomyosis
Conservative Definition: Extension of endometrial glands & stoma into uterine
NSAIDS musculature > 2.5 cm beneath the basalis layer.
(analgesics±paracetamol/codeine)
Laparoscopy
Combined oral contraceptive (standard) with intra- Patients are usually multiparous and diagnosed in their late 30’s
agents (reduce dysmenorrheal & abdominal lasers. or early 40’s. 15% have associated endometriosis.
1st
menorrhagia)
line Definitive Symptoms: Many asymptomatic, present with secondary
Progestogens
Medroxyprogesterone acetate spasmodic dysmenorrhea and menorrhagia.
Dydrogesterone Hysterectomy and
(Pesudo-decidualization of bilateral salpingo- Signs: Bulky, tender uterus particularly premenstrually.
endometrium) oophorectomy. Invest.: MRI method of choice, image myometrium.
Danazol/gestrinone (weight
gain, acne) N.B. No evidence that Rx Rx: Conservative with NSAIDs and hormonoal control
GnRH Aganoist ( bone density) significantly improves fertility. (amnorrhea) are mainstay Rx (but returns). Hysterectomy only
± HRT definitive Rx.