Dr Safoura Rouholamin M.D Laparoscopy fellowship Endometriosis Dr Safoura Rouholamin M.D Laparoscopy fellowship

Endometriosis Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature. The pelvis is the most common site of endometriosis, but endometriotic implants may occur nearly anywhere in the body.

Endometriosis is a common gynecologic problem in reproductive-age women who have pelvic pain, dyspareunia, infertility.

The management of endometriosis is controversial, but randomized clinical studies have substantiated some therapeutic approaches.

Pathogenesis The implantation theory proposes that endometrial tissue desquamated during menstruation passes through the fallopian tubes, where it gains access to and implants on pelvic structures. The incidence of retrograde menstruation is similar in women with and without endometriosis.

development of endometriosis could depend on the quantity of endometrial tissue reaching the peritoneal cavity, specific factors enhancing attachment of endometrial cells to the peritoneum and ovary, or the capacity of a woman's innate immune system to remove the refluxed menstrual debris

The direct transplantation theory is the probable explanation for endometriosis that develops in episiotomy, cesarean section, and other scars following surgery

The coelomic metaplasia theory proposes that the coelomic (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue. This theory is based on embryologic studies demonstrating that all pelvic organs, including the endometrium, are derived from the cells lining the coelomic cavity

Pelvic endometriosis is present in approximately 1% of women undergoing major surgery for all gynecologic indications, 6% to 43% of women undergoing sterilization, 12% to 32% when laparoscopy is performed to determine the cause of pelvic pain in reproductive-age women, and 21% to 48% of women undergoing laparoscopy for infertility. Endometriosis is found in 50% of teenagers undergoing laparoscopy for evaluation of chronic pelvic pain or dysmenorrhea.

Epidemiology The influence of age, socioeconomic status, and race on the prevalence of endometriosis remains controversial. The age at time of diagnosis is commonly 25 to 35 years, and endometriosis rarely is diagnosed in postmenopausal women. Many believe that endometriosis is more common in women of upper economic classes because they delay pregnancy, which is postulated to increase the risk of developing endometriosis

Pathology The most common sites of endometriosis, in decreasing order of frequency, are the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon, appendix, and round ligaments. Other sites less commonly involved include the vagina, cervix, and rectovaginal septum. These latter lesions usually result from extension and invasion of posterior cul-de-sac implants.

Macroscopic Appearance Endometriotic implants have a variety of appearances. Superficial lesions on the ovarian or peritoneal surface commonly are reddish maculae or nodules similar in consistency to normal endometrium. These implants vary from 1 mm to several centimeters in size. Collection of hemosiderin results in yellow-brown or black discoloration (powder-burn lesions). Nonpigmented disease appears as whitish opacified peritoneum, translucent blebs, or pinkish polyploid implants

Endometriosis also may appear as a deeply infiltrative disease. Tumorlike masses form from invasion, and diffuse fibrosis usually develops in the posterior cul-de-sac, pelvic sidewall, or posterior broad ligament and ovary and may extend deep into the retroperitoneal space, occasionally constricting the ureter. Lesions in the cul-de-sac may invade the rectovaginal septum.

Microscopic Appearance The four major components of endometriotic implants are endometrial glands, endometrial stroma, fibrosis, and hemorrhage. The relative amount of each component is highly variable and dependent, in part, on the age and location of the lesions. Identifying the endometrial elements in individual implants requires an adequate tissue specimen, proper orientation, and often serial sections of the specimen

Malignant transformation of endometriosis is uncommon. In one literature review, the prevalence of endometriosis in mucinous, serous, endometrioid, and clear cell ovarian carcinoma was 1%, 5%, 19%, and 36%, respectively

Symptoms common signs and symptoms of endometriosis are pelvic pain, dysmenorrhea, dyspareunia, abnormal uterine bleeding, and infertility. The type and severity of symptoms are dependent on the extent of disease, the location, and the organs involved

The discomfort may be unilateral or bilateral, and many patients complain of rectal pressure or low backache. Acute abdominal pain may result from hemorrhage secondary to a ruptured endometrioma.

Dysmenorrhea is a more frequent complaint than dyspareunia. There is some correlation between the extent of disease and the severity of pain. The morphologic appearance of an endometriotic implant appears to be unrelated to pain symptomatology. Dyspareunia is more common in women with invasive endometriotic nodules in the cul-de-sac, uterosacral ligaments, rectovaginal septum, and vagina

Abnormal uterine bleeding occurs in up to one third of women with endometriosis with symptoms of oligomenorrhea, polymenorrhea, and midcycle or premenstrual spotting. The abnormal bleeding likely results from conditions associated with endometriosis: oligoanovulatory luteinized unruptured follicles, luteal phase defects, and other pathology such as uterine fibroids

Endometriosis involving the gastrointestinal or urinary tracts and extrapelvic sites causes symptoms characteristic of the location of disease. Bladder involvement is associated with frequency and urgency. Invasion of the mucosa results in hematuria. Ureteral and rare cases of renal endometriosis occasionally cause flank pain or gross hematuria. Symptoms suggestive of gastrointestinal involvement include, in decreasing order of frequency, diarrhea, rectal bleeding, constipation, and dyschezia. All symptoms usually are exacerbated catamenially

It is estimated that 25% to 50% of infertile women have endometriosis and that 30% to 50% of women with endometriosis are infertile. Although the association of endometriosis and infertility is well recognized, the pathophysiologic mechanisms are poorly understood. Endometriomas and endometriosis with adhesions distort pelvic anatomy and impair tubal ovum pickup, which is an acceptable explanation for infertility.

Proposed Mediators and Mechanisms of Infertility Anatomic distortion and tubal obstruction Anovulation, luteal phase defects, and hormonal abnormalities Galactorrhea or hyperprolactinemia Autoimmunity Peritoneal leukocytes and the peritoneal inflammatory response Peritoneal fluid prostaglandins Peritoneal fluid cytokines Embryo implantations defect and spontaneous abortions

Diagnosis Endometriosis usually is diagnosed during the third and fourth decades of life. It has not been found in prepubertal girls and rarely is diagnosed in postmenopausal women unless they are taking replacement hormones. Endometriosis should be suspected in any woman having the classic symptoms of pelvic pain, dysmenorrhea, dyspareunia, abnormal menstrual bleeding, and infertility. These symptoms are present in other gynecologic disorders.

Physical findings in women with endometriosis are variable and dependent on the location and severity of disease Frequently, there are no obvious findings on pelvic examination. When findings are present, the most common is tenderness when palpating the posterior fornix. Nodules of endometriosis on the uterosacral ligaments, enlarged ovaries as a result of endometriotic cysts, and a uterus fixed in the cul-de-sac by adhesions may be detected during a pelvic examination. Uterosacral implants are best palpated during a rectovaginal examination.

Because endometriosis is located primarily in the pelvis, laparoscopy is the preferred technique to make an accurate diagnosis. A double-puncture technique is necessary to adequately view all structures that may contain implants. Peritoneal fluid should be aspirated to see the entire cul-de-sac. Adhesions should be lysed to view the entire surface of the ovaries and the fossa ovarica. These sites are commonly involved with endometriosis when the ovary is adherent to the pelvic sidewall. Suspected endometriomas should be aspirated and resected to confirm the diagnosis. Biopsy and histologic study of any suspicious areas are helpful when the diagnosis is questionable, but often the visual diagnosis by the surgeon is more accurate than histologic sections of small peritoneal biopsies

Clinical Signs Localized tenderness in the cul-de-sac or uterosacral ligament Palpable tender nodules in the cull-de-sac, uterosacral ligament, or rectovaginal septum Pain with uterine movement Tender, enlarged adnexal masses Fixation of adnexa or uterus in retroverted position

Transvaginal ultrasonography can be used to identify ovarian endometriomas, but it is of little utility to diagnose peritoneal implants. The use of other radiologic studies and blood tests to diagnose endometriosis rarely is required. Radioimmunoassay for the tumor marker CA-125 has been used, but the test is not sufficiently sensitive or specific, and patients having conditions other than endometriosis may have positive results

Classification The most widely used system was introduced by the American Society for Reproductive Medicine (ASRM) in 1979 and revised in 1985 and in 1996. This system assigns a point score for the size and location of endometriotic implants and associated adhesions. The new ASRM endometriosis classification for infertility includes the morphologic appearance of the implant. There is a form published by the ASRM to assist in the management of endometriosis in the presence of pelvic pain.

Endometriosis is classified as minimal, mild, moderate, and severe. Mild disease is characterized by superficial implants <5 cm2 in aggregate scattered on the peritoneum and ovaries. Minimal or no adhesions are present. Moderate forms are characterized by multiple implants, both superficial and invasive. Peritubal and periovarian adhesions may be evident. Severe forms are characterized by multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions usually are present. However, no staging system has been validated to correlate with the symptoms of pain or infertility.

Treatment Expectant Management Medical therapy    Progestins    Levonorgestrel-releasing intrauterine device    Danazol    GnRH analogues    Aromatase inhibitors Surgical therapy (laparoscopy or laparotomy)    Conservative: retains uterus and ovarian tissue    Definitive: removal of uterus and possibly ovaries Combination therapy    Preoperative medical therapy    Postoperative medical therapy

Medical Therapy The medications used most commonly to treat endometriosis are continuous oral contraceptives, progestins, danazol, and GnRH analogues. They should be considered after a definitive diagnosis of endometriosis has been made by direct visualization of the implants. The GnRH analogues profoundly suppress ovarian estrogen production by inhibiting pituitary gonadotropin secretion

Surgical Management Surgery for endometriosis is considered conservative when the uterus and as much ovarian tissue as possible are preserved. Definitive surgery involves hysterectomy with or without removal of the fallopian tubes and ovaries.

Surgery is indicated when the symptoms are severe, incapacitating, or acute and when the disease is advanced. Surgery is preferred over medical therapy for advanced stages of disease with anatomic distortion of the pelvic organs, endometriotic cysts, or obstruction of the bowel or urinary tract. Women who are older than 35 years, infertile, or symptomatic following expectant or medical management should be treated surgically

Laparoscopy is the preferred approach to perform conservative surgery. Treatment of endometriosis is possible during the initial laparoscopy, which is used to diagnose the condition. This offers the advantage of ablating the implants and adhesions while avoiding possible progression of disease or symptoms and the expense and side effects of medical therapy. Disadvantages include possible damage to the bowel and bladder, infection, and mechanical trauma that may result in adhesion formation

Conservative surgery involves excision, fulguration, or laser ablation of endometriotic implants and removal of associated adhesions. The goal is to restore normal pelvic anatomy. Laparoscopic treatment offers advantages over laparotomy, including shorter hospitalization, anesthesia, and recuperation times. Laparotomy is advisable to deal with extensive adhesions or invasive endometriosis located near structures such as the uterine arteries, ureter, bladder, and bowel.

The disease recurrence risk is estimated to be as much as 40% with 10 years of follow-up. Pain relief is achieved in 80% to 90% of patients. Presacral neurectomy provides additional pain relief, but its benefit is not lasting, and bladder dysfunction occasionally occurs after the procedure. The chance for pregnancy following surgery is related to the stage of disease and presence of other infertility factors

Definitive surgery for treatment of endometriosis is indicated when significant disease is present and pregnancy is not desired, when incapacitating symptoms persist following medical therapy or conservative surgery, and when coexisting pelvic pathology requires hysterectomy. The decision to perform hysterectomy is dependent primarily on the patient's interest in maintaining childbearing potential and the severity of her symptoms.

The ovaries may be conserved in younger women to avoid the need for estrogen replacement therapy. Removal of both ovaries is appropriate when the ovaries are damaged extensively by endometriosis or when menopause is approaching. Endometriosis may recur even with castration, presumably from microscopic foci of disease not visible at surgery

Combination Medical and Surgical Therapy Medical therapy is used before surgery to decrease the size of endometriotic implants and thus reduce the extent of surgery. When complete removal of implants is not possible or advisable, postoperative medical therapy is used to treat residual disease. Progestin, danazol, or GnRH analogues may be used in conjunction with conservative or definitive surgery. Preoperative medical therapy may decrease the amount of surgical dissection required to remove implants, but it does not prolong pain relief, increase pregnancy rates, or decrease recurrence rates. Postoperative treatment with GnRH analogues will somewhat delay the recurrence of pelvic pain, but there is no evidence to support its use in infertile patients.