DR.A. RATHNA M.

S ( O&G )
I st YEAR PG

Endometriosis
Endometriosis is a disease in which

endometrial glands and stroma implant

and grow in areas outside the uterus

Most commonly implants are found in

the pelvis

Lesions may occur at distant sites:

pleural cavity, liver, kidney, gluteal

muscles, bladder, etc

Features of
Endometriosis
Prevalence 2-50% of women; 21-47% of
infertility cases
Exposure to ovarian hormones appears to

be essential
No known racial or socioeconomic

predilection
Severe disease may occur in families

Is Endometriosis
Increasing?
1965-1984, endometriosis rose from 10 to
19% as primary indication for hysterectomy
Simultaneously, a trend of more conservative

therapies was occurring, which suggests a

true increase in the incidence
Theories include delay of childbearing, less

use of OCs, and exposure to environmental

toxins such as dioxin

Normal Pelvic
Structures

DrMonaShroff
www.obgyntoday.info

ENDOMETRIOSIS

- Pelvic
- Extra pelvic
Umbilicus.
Scars (Lap.).
Lungs & plura.
Others.

Uterine= Adenomyosis (50%).

Extraut:
- Ovary 30%
- Pelvic peritoneum 10%.
- F. tube.
- Vagina.
-Bladder & rectum.
- Pelvic colon.
- Ligaments.

DrMonaShroff
www.obgyntoday.info

Signs and Symptoms

Chronic Pelvic Pain, Dysmenorrhea
Abnormal Uterine Bleeding
Infertility
Deep Dyspareunia
Pelvic Mass (Endometrioma)
Misc: Tenesmus, Hematuria, Hemoptysis

Pelvic examination may

reveal:
1. Pelvic tenderness.
2. Fixed retroverted uterus.
3. Nodularity of the Douglas pouch and
uterosacral ligaments.
4. Ovaries may be enlarged and tender .
Ovarian cyst may be detected.

Etiology: Theories
Sampson: Retrograde Menstruation
Hematologic Spread
Lymphatic Spread
Coelomic Metaplasia
Genetic Factors
Immune Factors
Combination of the Above
No Single Theory Explains All Cases of
Endometriosis

Etiologies of
Endometriosis
Sampson's theory: Retrograde menses and
peritoneal implantation

Most women retrograde menstruate

Meyer's theory: Coelomic metaplasia

Low incidence of pleural disease

Halban's theory: Hematogenous or

lymphatic spread to distant tissues

Does not explain gravity dependent disease

sites

Immunogenic defect

Diagnosis
Laparoscopy (Gold Standard)
Laparotomy
Inconclusive: CA-125, Pelvic Exam, History,

Imaging Studies
Biopsy Preferable Over Visual Inspection

Appearance
Endometriosis May Appear
Brown
Black (Powderburn)
Clear (Atypical)
Endometriosis May Be Associated with
Peritoneal Windows

DrMonaShroff
www.obgyntoday.info

DrMonaShroff
www.obgyntoday.info

Treatment: Overall
Approach

Recognize Goals:
Pain Management
Preservation / Restoration of Fertility
Discuss with Patient:
Disease may be Chronic and Not Curable
Optimal Treatment Unproven or Nonexistent

Treatment :
Consideration
Age.
Symptoms.
Stage.
Infertility.

Classification / Staging
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

DrMonaShroff
www.obgyntoday.info

DrMonaShroff
www.obgyntoday.info

Pain Management: Medical

Therapy

NSAIDs
OCPs (Continuous)
Progestins
Danazol
GnRH-a
GnRH-a + Add-Back Therapy
Aromatase Inhibitors
Misc: Opoids, SSRIs

Indications of
Hormonal Rx
1. Small endometriotic; lesions.
2. Recurrence after conservative
surgery.
3. Preoperative for 6-12 weeks to
decrease size.
4. Postoperative for residual lesions.
5. When operation is contraindicated
or refused by the patient.

Aim of the hormonal

therapy
(A) Pseudopregnancy :

1. Combined low - dose contraceptive pills(6 - 18

months to inhibit ovulation and menstruation and
induce decidualization to endometriotic tissues).

or
2. Progestins (to avoid oestrogen's side effects medroxy
progesterone acetate Depo medroxy progesterone
acetate (DMPA) can be given in a dose of 150 mg IM
every I - 3 months .

Aim of the hormonal

therapy cont.
(B) Pseudomenopause
(induction of amenorrhoea)
by:
1. Danazol.
2. Gn RH analogues.
3. Gestrinone.
4. Gossypol.

Continuous OCPs
Pseudopregnancy (Kistner)
? Minimizes Retrograde Menstruation
Lower Fertility Rates than Other Medical

Treatments
Choose OCPs with Least Estrogenic Effects,
Maximal Androgenic / Progestin Effects

Progestins
May be as Effective as GnRH-a for Pain Control
MPA 10-30 mg/day, DP 150 mg Semi-Monthly
May be Taken Long-Term
Relatively Inexpensive
Side-Effects: AUB, Mood Swings, Weight Gain,

Amenorrhea

Danazol
Weak Androgen
Suppresses LH / FSH
Causes Endometrial Regression, Atrophy
Expensive
Side-Effects: Weight Gain, Masculinization,

Occ. Permanent Vocal Changes

GnRH-a
(Leuprolide,triptorelin)
Initially Stimulate FSH / LH Release
Down-Regulates GnRH

ReceptorsPseudomenopause
Long-Term Success Varies
Expensive
Use Limited by Hypoestrogenic Effects
May be Combined with Add-Back (? >1 Year )

Aromatase Inhibitors
Blocking the aromatase activity in

extraovarian sites that suppress the

conversion of androstenedione and
testosterone to estrogen. May result in
suppression of endometriosis at a local level.
Further studies needed
2.5 mg PO qd for 6 mo; administer with
norethindrone acetate 2.5 mg PO qd

Gestrinone
It is a synthetic 19 Nor steroid exhibits

marked and - progcs-terogenic and anti oestrogenic as well as mild androgenic and
anti -gonadotrophic properties .
The endocrine effects of Gestrinone are
similar to those of Danazol which leads
mainly to inhibition of ovarian
steroidogenesis .
The dose is 2.5 - 5 mg orally twice weekly .

Surgical Treatment
(Laparoscopy / Laparotomy)
/

Excision Fulgration ELECTROCAUTRY/LASER)

Resection of Endometrioma
Lysis of Adhesions, Cul-de-sac Reconstruction
Uterosacral Nerve Ablation
Presacral Neurectomy
Appendectomy
Uterine Suspension (? Efficacy)
Hysterectomy +/- BSO

Conclusion
Endometriosis is a Common, Chronic Disease
Typical Symptoms Include Pain, Infertility,

Abnormal Uterine Bleeding

The Optimal Treatment Remains Unclear
Surgical Excision is the Most Efficacious
Approach with Respect to Fertility
Better Medical Therapies are Needed

THANK YOU

DrMonaShroff
www.obgyntoday.info