Endometriosis Overview

Endometriosis-An Overview
Prof. Dr. Mohammad A. Emam
Prof. of Obstetrics and Gynecology
Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center (MIFC) Egypt
Emam MA, EGYPT, 2003

Definition
"Presence of endometrial tissue outside the lining of the uterine cavity" or
"Proliferation of endometrium in any site other than the uterine mucosa."

Epidemiology
• Age: common in reproductive period
• True Incidence Unknown: ? 1-5% & 30-50% infertility.
• Does NOT Discriminate by Race.
• Histology: Endometrial Glands with Strom +/- Inflammatory Reaction.
• Herdietary (↑↑ among sisters)

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

Pelvic Endometriosis
• Uterine= Adenomyosis (50%).
• Extraut:
- Ovary 30%
- Pelvic peritoneum 10%
- F. tube.
- Vagina.
- Bladder & rectum.
- Pelvic colon.
- Ligaments.
Emam,MA, EGYPT, 2003

Theories of histiogenesis
• Endometrial implantation theory
Retrograde
Vascular and lymphatic
Mechanical
• Immunological and genetic theory
• Composite theory

Theories of Histiogenesis
• In situ development
• Coelomic metaplasia theory
• Induction theory
• Embryonic cell nest
• Wolffian ducts
• Mullerian ducts
• Germinal epithelium of ovary

Predisposing Factors
1. Hyperoestrinism:
a) Fibroid & metropathia hemorrhagica.
b) Delayed marriage, inferility.
c) Oestrogen secreting tumours of the ovary e.g. granulosa & theca cell tumors, or with prolonged oestrogen therapy.
2. Cervical Stenosis.
3. Unsufflation.
4. Curettage.
Emam MA, EGYPT, 2003

Macroscopic appearance
1) Uterine endometriosis "Adenomyosis":
a) Diffuse (Common)
* The uterus is symmetrically enlarged
* Firm in consistency
b) Localized (occasional)
* The uterus is asymmetrical enlarged
* Firm in consistency
In both types:
C/S a whorled appearance.
D.D. * No capsule.
Dark brown spots.
* M/E endometrial tissue.
Emam MA, EGYPT, 2003

Macroscopic appearance
2) Endometriosis of the ovary:
- The ovary is enlarged and cystic.
- Surface burnt match head appearance.
- Tunica albuginea --> thickened.
• Chocolate or tarry cysts.
Emam MA, EGYPT, 2003

Diagnosis
• Endometriosis is often misdiagnosed leading to delays in treatment sometimes for several years.
• Delay in diagnosis:
- Progression of symptoms.
- Increasing infertility till completed reproductive failure.
Emam MA, EGYPT, 2003

Diagnosis
• Symptoms (history).
• Signs (Exam).
• Investigations.
• DD.

Symptoms
• Asymptomatic.
• Pain (DYS.....):
- Dysmenorrhea (crescendo=progressive)
- Dyspareunia.
- Dyschesia.
Dysuria.
• Backache.
• Acute abdomen.
• premenst. Tension syndrome.
Emam MA, EGYPT, 2003

Symptoms cont...
• Bleeding:
- Menorrhagia.
- Cyclic hematuria during menstration.
- Cyclic bleeding per rectum during menstration.
- Vicarious menstration.
• Infertility.
• Mass
Emam MA, EGYPT, 2003

Signs
Pelvic examination may reveal:
1. Pelvic tenderness.
2. Fixed retroverted uterus.
3. Nodularity of the Douglas pouch nd uteroscacral ligaments.
4. Ovaries may be enlarged and tender. Ovarian cyst may be detected.
Emam MA, EGYPT, 2003

Investigations
1. Laparoscopy.
2. Cystoscopy and proctosigmoidoscopy.
3. Histopathological examination.
4. Imaging.
5. Serum CA - 125.
6. ? IL-8 & CEA.
Emam MA, EGYPT, 2003

Laparoscopy
• Value:
It permits a "see and treat" approach, although its effectiveness may be limited by the nature of the disease and the surgeon's skill.

Laparoscopy
Appearance:
Endometriosis May Appear
• Brown
• Black ("Powderburn")
• Clear ("Atypical")
Endometriosis May be associated with Peritoneal windows
Emam MA, EGYPT, 2003

Differential diagnosis
1. Ovarian cysts.
2. Pelvic inflammatory disease.
3. Other causes of nodularity in Douglas pouch as tuberculous peritonitis and metastases of ovarian cancer.
4. Causes of haematuria, bleeding per rectum and acute abdominal pain if the patient is presented by one of these symptoms.
5. Asymmetrical enlarged uterus.
Emam MA, EGYPT, 2003

Ovarian Endometriosis (Endometrioma)
• Formed by invagination of the ovarian cortex after accumulation of menstrual debris from bleeding of endometriotic implants.
Emam MA, EGYPT, 2003

Rectovaginal Septum Endometriosis
• Nodules are formed by hyperplasia of smooth muscles and fibrous tissue surrounding the infiltrated tissue.
• No cyclical bleeding as the endometriotic tissue are enclosed in nodules.
Emam MA, EGYPT, 2003

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.
Emam MA, EGYPT, 2003

Revised AFS 1985
• Stage I (minimal) 1-5.
• Stage II (mild) 6-15.
• Stage III (moderate) 16-40.
• Stage IV (severe) > 40.
Emam MA, EGYPT, 2003

Treatment: Consideration
• Age.
• Symptoms.
• Stage.
Intertility.
Emam MA, EGYPT, 2003

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

Edometriosis & IVF
• The presence of endometriosis does not generally impair the results of IVF but it increases the risk of infection.
• It is perferable not to cauterize ovarian endometrioma if IVF or ICSI is indicated for fear of destruction of ovarian tissues.
Emam MA, EGYPT, 2003

Lines of ttt
• Expectant.
• Medical.
• Hormonal.
• Surgical.
Emam MA, EGYPT, 2003

(I) Expectant treatment
• Young, asymptomatic infertile patient with mild endometriosis.
• If pregnancy does not achieved within 12-18 months of observation:
- hormonal or surgical treatment is indicated.
Emam MA, EGYPT, 2003

(II) Medical Treatment
• Symptomatizing patients with minimal or mild lesions:
1. Analgesics: for pain.
2. Prostaglandin inhibitors.
3. Pregnancy.
4. Opoids.
Emam MA, EGYPT, 2003

(III) Hormonal treatment
• Oestrogen.
• Combined oestrogen-progestogen pills.
• Progestins.
• Danazol.
GnRH agnotists.
Emam MA, EGYPT, 2003

Indications of Hormonal ttt
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.
Emam MA, EGYPT, 2003

Aim of the hormonal therapy
(A) Pseudopregnancy:
1. Combined low - dose contraceptive pills (6-18 months to inhibit ovulation and menstration 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.
Emam MA, EGYPT, 2003

Aim of the hormonal therapy
(B) Pseudomenopause (induction of amenorrhoea) by:
1. Danazol.
2. Gn RH analogues.
3. Gestrinone.
4. Gossypol.
Emam MA, EGYPT, 2003

Danazol
• Weak Androgen (isoxazole derivative of 16 - alpha ethinyl testosterone).
• Suppresses LH/FSH.
• Causes Endometrial Regression, Atrophy.
• Expensive.
• Dose 400- 800 mgm orally / day/ 6-9 months.
• Side-effects: Weight Gain, Masculinization, Occ. Permanent Vocal
Emam MA, EGYPT, 2003

GnRH-a
• Initially Stimulate FSH/LH Release.
• Down-Regulates GnRH Receptors-"Pseudomenopause".
• Long-term Success Varies.
• Expensive.
• Use Limited by Hypoestrogenic Effects.
• May be Combined with Add-Back (?>1 Year), using E2/progesterone preparation.
Emam MA, EGYPT, 2003

GnRH-a
Addback (E2/progesterone preparation):
• Reduce effect on bone mineral density.
• Relieve hot flushes.
Emam MA, EGYPT, 2003

Gossypol
• Is a phenolic compound extracted from the seed, stem and root of the cotton plant.
• It is a suppressor of FSH and LH, producing endometrial atrophy in about 50% of patients after 3 months.
• Dose: 20 mg daily for 2 months then 25 mg twice weekly for maintenance.
• Side effects: include electrolyte disturbance especially hypokalaemia and alteration of hepatic and renal function.
Emam MA, EGYPT, 2003

Gestrinone
• It is a synthetic 19 Nor steroid exhibits marked and progesterogenic 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.
Emam MA, EGYPT, 2003

Surgical Treatment (Laparoscopy /Laparotomy)
• Excision si/ Fulgeraton no!
• Resection of Endometrioma.
• Lysis of Adhesions, Cul-de-sac Reconstruction.
• Uterosacral Nerve Ablation.
• Presacral Neurectomy.
• Appendectomy.
• Uterine Suspension (? Efficacy).
• Hysterectomy +/- BSO.
Emam MA, EGYPT, 2003

Issues
• ? Removal of Ovaries at Hysterectomy
• ? Need for Progestins if ERT Given
• ? Adjuvant Treatment Postoperatively
• ? Lupron Challenges Test for Diagnosis
• • ? Is Endometriosis Best treated Surgically, Medically or Both

Conservative surgery
1. Large adnexal masses.
2. Failure of medical and hormonal treatment.
3. Severe endometriosis (follow principles of microsurgery).
Emam MA, EGYPT, 2003

The Principles of Microsurgical Technique
1. The use of magnification by microscope or head loupes.
2. gentle handling of tissues.
3. meticulous tissue dissection.
4. precise haemostasis.
5. careful approximation of tissues.
Emam MA, EGYPT, 2003

The Principles of Microsurgical Technique
6. Irrigation of the field with heparined Ringer's lactate.
7. The use of non- or delayed absorbable suture material, cut gut should be avoided as it is irritant to the tissue.
8. Contamination of the pelvis with foreign material as talc powder from gloves should be avoided as it provokes inflammation.
9. Intra- operative dextran 70.
10. postoperative corlicosteroids and prophylactic antibiotics may be used.
Emam MA, EGYPT, 2003

Conclusion
• Endometriosis is a mystery tour as it requires decision making at every stage by the physician and the patient.
• Endometriosis still stand as one of the most-investigated disorders in gynecology. So is one of the highest priorities for research.

Thank you
Prof. DR. MOHAMMAD EMAM,
OB& GYN, Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center (MIFC) EGYPT
Telfax 0020502319922 & 002050231229
Email. mae335@hotmail.com
Emam MA, EGYPT, 2003