ENDOMETRIOSIS

Endometriosis definition The presence of endometrial tissue in extrauterine locations .

Endometriosis - pathogenesis The exact pathogenesis is unknown Three major theories: Theory of the implantation (Sampson´s theory) – direct implantation of endometrial cells, typically by means of retrograde menstruation.

Endometriosis pathogenesis Coelomic metaplasia of multipotential cells in the peritoneal cavity (Meyers theory) states that, under certain conditions m-p cells can develop into endometrial tissue Vascular and lymphatic dissemination of endometrial cells (Halbans theory) – distant sites of endometriosis can be explained by this process ( lymph nodes, pleura, kidney)

Endometriosis division by Semm Internal endometriosis of genital organs Adenomyosis (endometrial tissue in uterine wall) Adenomyoma (endometrial tissue in uterine myomas) Endometriosis in the wall of uterine tube

Endometriosis division by Semm External endometriosis of genital organs: Ovary: - endometrioma (the endometrial tissue deeply in ovary tissue as a tumor) - on the surface of ovary. Uterosacral ligaments, round ligament of the uterus. Uterine tubes

Endometriosis division by Semm External endometriosis of genital organs: Anterior et posterior cul-de-sacs Pelvic peritoneum over uterus Uterine cervix Fornix of the vagina, vagina Perineum

Endometriosis division by Semm Extragenital endometriosis Sigmoid colon, ampula of the rectum, cecum, appendix Urinary bladder Umbilicus Postoperative scars (laparotomia, cesarean section)

Endometriosis division by Semm Extragenital endometriosis Omentum Small intestine Femoral canal Arms, legs Lungs, pleura Brain Kidney

Endometriosis the most common sites Surface of the ovary – 60 – 70% Endomerioma (ovary) – 30-40% Peritoneum over the uterus – 40-50% Uterine tube and mesosalpinx – 20 – 30% Posterior cul–de–sac - 20- 30% Uterosacral ligaments - 20-25% Rectosigmoid - 7-10%

Endometriosis symptoms Pelvic pain Dysmenorrhea Dyspaurenia Dysuria, hematuria Dyschesia, rectal bleeding Abnormal bleeding (irregular menstrual periods, premenstrual spotting)

Endometriosis complications Infertility Abortions Acute abdominal emergency (rupture or torsion of an endometrioma)

Infertility The higher stage of endometriosis – In the group of infertile women the endometriosis occurs in 30-50% In the group of women with the endometriosis infertility occurs in 30-70% The higher stage of endometriosis – the lower chance of pregnancy.

Infertility reasons Distortion of the elements of the reproductive tract and damage to the ovary (obstruction of the uterine tube, adhesions, cysts) Functional infertility (the influence of prostaglandin, IL-5, IL-6, complement: C3,C4 macrophages, LT helper, LT supresors, NK - anovulation, luteal phase inadequacy, phagocytosis of sperm, oocytes, unproper conditions to the implantation

Endometriosis the risk factors Congenital anomalies that promote retrograde menstruation Short period, long lasting menstruation Dysmenorrhea Infertility First and second degree relatives have had endometriosis

Endometriosis diagnosis Anamnesis Physical examination Laboratory studies are not useful at making the diagnosis but helpful in the differential diagnosis Pelvic ultrasound Laparoscopy Histopathological examination

Endometriosis diagnosis Establishing a diagnosis requires direct visualisation at the time of the diagnostic laparoscopy or the laparotomy Histopatological confirmation of endometriosis is „the gold standard”

Laparoscopy / Laparotomy description of the lesions Peritoneum: vascular hemorrhagic areas, white - opaque plaques, spots described as „mulberry” or „raspberry”, fibrosis surrounding these lesions, adhesions Ovary : endometriomas – filled with thick, chockolate-appearing fluid; superficial implants Uterine tubes: tubal occlusion, adhesions, distortion Uterus: superficial implants, retroverted and fixed

Endometriosis staging Classification system by the AFS Stage I – minimal 1-5 Stage II – mild 6-15 Stage III – moderate 16-40 Stage IV – severe >40 Evaluation of areas of endometriosis (size,localization); adhesions (types, localization), posterior cul-desac obliteration, tubal occlusion

Endometriosis differential diagnosis Abdominal pain ( PID, GI dysfunction, adhesions, tumors) Dysmenorrhea Dyspaurenia (PID, colpitis, uterine retroversion) Abnormal bleeding (hormonal dissfunction, polyps, cervical lesions)

Endometriosis differential diagnosis Acute abdominal emergency (ectopic pregnancy, adnexal torsion, rupture of corpus luteum, acute PID – peritonitis) Dysuria, dyschesia, hematuria, rectal beeding, hemoptysis, tumor in the scar - rare symptoms

Endometriosis treatment The choice of therapy depends on Presenting symptoms and their severity Location and severity of endometriosis Desire for future childbearing

Endometriosis treatment 3 stages of the treatment by Semm I stage: laparoscopy - surgical tratment: electrocoagulation of endometriosis, removal of the cysts and adhesions II stage: medical therapy 3 – 6 months III stage: surgical therapy – removal of remaining endometriosis, salpingoplasty

Endometriosis medical therapy 3 groups of medicines: Danazol Progestins Gonadotropin-releasing hormone agonists

Progestins endometriosis treatment Medroxyprogesterone acetate Provera tb 20 – 40 mg/d Depomedroxyprogesterone acetate Depo-Provera inj. i.m. 100 mg / 2 weeks – 8 weeks, than 200 mg/1 month

Progestins endometriosis treatment Progestins supress FSH/LH release and ovarian steroidogenesis „a state of pseodopregnancy”

Progestins endometriosis treatment Adverse effects: nervous system - depresion, headache, vertigo, nervosity; skin - oily skin, itch, hirsutism; mastalgia, nausea, weight gain; thrombosis, alterations of lipoprotein, glucose and Ca and P metabolism

Danazol endometriosis treatment Danazol-17α-ethinyl testosterone derivative tb 600 - 800 mg/d – 1 month, than 400 mg up to 6 months Supresses FSH/LH release and steroidogenesis endometrial atrophy „a state of pseudomenopause”

Danazol endometriosis treatment Adverse effects: hypoestrogenic and androgenic properties: acne , oily skin, hirsutism, spotting, bleeding, hot flushes, atrophic vaginitis nausea, depresion, nervosity, headache, vomit, alterations of lipoprotein, glucose, Ca and P metabolism

GnRh agonists endometriosis treatment Triptorelin – Decapeptyl depot a 3.75 mg inj i.m. 1x/28d, Dipherelinum SR a 3.75 mg inj i.m. 1x/28d Goserelin – Zoladex a 3.6 mg inj s.c 1x/28d Therapy 3 – 6 months

GnRh agonists endometriosis treatment Pituitary desensybilisation supress FSH/LH release „a state of pseudomenopase”

GnRh agonists endometriosis treatment Adverse effects: hypoestrogenic propierties without androgenic effects The most expensive therapy but the most effective one