Endometriosis😍

Endometriosis

Endometriosis

• Definition: All three components must be present outside uterus.
1. Glands
2. Stroma
3. Hemosiderin

General Points

• Most common site: Ovary
• Often as "Chocolate cyst" or "endometrioma"





• (molten chocolate appearance from old blood)

• Other common sites:
• Posterior cul-de-sac (POD) >
• Broad ligament (BL) >
• Uterosacral (US) ligament

• Least common sites:
• Spleen
• Central Nervous System (CNS)

• Sampson theory of implantation/retrograde menstruation
• Most accepted theory (Ovary, POD):

• Halban theory (Umbilicus):
• Lymphatic spread

• Ivanoff theory (Distant sites, e.g., lungs):
• Lymphatic spread

• Scar endometriosis:
• Due to direct spread
• Common after:
• Episiotomy
• Caesarean section
• Hysterotomy
• Myomectomy
• Least likely after: Hysterectomy

Symptoms

• Age group:
• Reproductive age (25-35 years)
• Common in nulliparous females

• Least common in: Pubertal females
• Note: Suspect Mullerian malformations if in pubertal females

• Most common symptom: Pain
• Dysmenorrhea
• Chronic pelvic pain
• Dyspareunia

• Second most common symptom: Infertility

• Third most common symptom: Adnexal mass

• Most common cause of Secondary dysmenorrhea
• Note: Suspect Endometriosis with dysmenorrhea + dyspareunia

Examination Findings

• P/V exam: Often reveals nothing significant

• Uterus:
• May be retroverted and fixed
• Normal size, non-tender

• Adnexa:
• May show bilateral adnexal mass (chocolate cyst)
• Adnexal tenderness

• US ligament: May present with nodularity

• Note:
• Pain at surgical site increasing during periods suggests scar endometriosis
• Retroverted uterus → only 2 conditions
• Uterine Prolapse
• Endometriosis

Diagnosis of endometriosis

• 1st investigation: TVS
• Chocolate cyst may be seen

• IOC: Laparoscopy

• Gold Standard: Histopathological Examination (HPE)

• CA-125 levels: Increased (>100 IU)

• MRI: Used for bladder and bowel endometriosis
• Deep rectosigmoid endometriosis: "Mushroom cap sign"

Management of Endometriosis

Laparoscopic Findings

• "Red flame lesions" (new lesions)

• "Gunshot/powder burn appearance" (older lesions)

1. Dysmenorrhea

• Minimal/Mild:
• First line: OCPs
• If conceiving desired: NSAIDs
• Second line: Progesterone
• Third line: GnRH (continuous analogues or antagonists)
• If all three fail: Laparoscopy
• Mnemonic: Oh (OCP) Pain (Progest) Girl (Gnrh) Lie (Lap)

• Moderate/Severe:
• First line:
• Continuous GnRH analogues
• GnRH antagonists
• If it fails:
• Laparoscopy
• Helps in confirming diagnosis.
• Sampling for HPE.
• Grading the disease.
• Laparoscopic pain management:
• Fulguration of implants.
• Adhesiolysis.
• Laparoscopic uterosacral nerve ablation (LUNA).
• Other drugs:
• Letrozole
• Danazol (Side effect: Hirsutism)
• Theoretically usable (not FDA approved):
• Mifepristone (causes instant endometrial atrophy)
• Last resort: Total Abdominal Hysterectomy (TAH) (stops retrograde menstruation)

• Note: Pain is proportional to depth of lesion

• Mnemonic for drugs that decrease estrogen:
• Dominos Pizza Got Late
• Danazol
• Progesterone
• GnRH
• Letrozole

2. Endometrioma (Chocolate Cyst)

3. Infertility

• Minimal/Mild symptoms
• taken as unexplained infertility:
• IUI (Intrauterine Insemination)
• Clomiphene citrate

• Mod/severe symptoms
• Infertility due to tubal block:
• IVF (In vitro fertilization)