1. Endometriosis
*Is the presence of endometrial glands and stroma outside the endometrial cavity and walls
*Deposits proliferate during the menstrual cycle, brake down & bleed with menstruation, causing local inflammatory reaction
*Fibrosis & distortion of the tissue affected with dense scarring.
Benign

2. Endometriosis Hormone dependant Responds to estrogen
Regress after menopause, oopherectomy and during pregnancy

3. Endometriosis Etiology
Unknown
Theories
Retrograde menstruation
Coelomic epithelium transformation
Lymphatic and vascular spread
Genetic and immunologic factors

4. Endometriosis Epidemiology
Disease of reproductive age group
Affect 5-15% of women
Diagnosed in 20-30% of women investigated for infertility
More in women whose first degree relative have the disease
Often diagnosed incidentally

5. Endometriosis High social class women in their thirties and infertile!
Can be diagnosed in any type of women and all age groups

6. Endometriosis Sites More commonly in the dependant part of the pelvis
Ovaries 2/3 of women
Broad ligament
Peritoneal surface of Cul-de-sac and uterosacral ligaments
Rectovaginal septum
Rectosigmoid colon
Distant and laparatomy scars

7. Endometriosis Pathology
Gross
Hemorrhagic vesicle Free
Papule and later nodule Enclosed
White nodules or flattened fibrotic scar Healed
Ovarian endometrioma is an enclosed hemorrhagic cyst of variable sizes

12. Endometriosis Histopathology
Active endometrial glands and stroma
Blood filled cystic lesions
Fibrosis with glands only no stroma
Adhesion formation

13. Endometriosis Symptoms
According to site
No relation between extent of the disease and severity of the symptoms
Often discovered incidentally

14. Endometriosis Symptoms
Female reproductive tract
Dysmenorrhea
Lower abdominal and pelvic pain
Dyspareunia
Accident to endometriotic cyst
Low back pain
Infertility
Menstrual irregularity !

15. Endometriosis Symptoms
Urinary tract
Cyclical haematuria / dysuria
Ureteric obstruction
Gastrointestinal tract
Dyschezia
Cyclical rectal bleeding
Intestinal obstruction

16. Endometriosis Symptoms
Surgical scar and umbilicus
Cyclical pain and bleeding
Lungs
Cyclical haemoptysis
Haemopneumothorax`

17. Endometriosis Clinical findings
Often Negative
Suggested by
Thickening and nodularity of uterosacral L.
Tenderness in POD
Ovarian mass/ masses
Fixed retroverted uterus
Tender nodule in the cervix, umbilicus or scar

18. Endometriosis Investigations
Ca 125 often elevated
Ultrasonography for ovarian cyst
MRI

19. Endometriosis DD All causes of chronic pelvic pain Acute conditions
Ectopic pregnancy
Acute PID
Complicated ovarian cyst
Acute appendicitis and other surgical emergencies

20. Endometriosis Diagnosis
Direct visualization of the lesion
Laparascopy
Laparatomy
Histopathology to confirm the diagnosis

21. Endometriosis Treatment
Non-steroidal anti-inflammatory agents
Induce Amenorrhea: Pseudopregnancy
Induce Amenorrhea: Pseudomenopause
Surgery

22. Endometriosis Treatment
Pseudo-pregnancy
Combined OCP continuous
Cyclical ?? of limited value
Side effect
Synthetic progestogens: Medroxyprogesterone acetate and dydrogesterone high doses continuous Side effect
Levonorgestrel-releasing system reduces dysmenorrhoea and regress POD implants

23. Endometriosis Treatment
Pseudomenopause
Danazol androgen derivative 6-9 months
Gestrinone, androgen derivative
Both drugs have androgenic side effects
GnRH agonists
Menopausal symptoms, Osteoporosis
? Add back therapy

24. Endometriosis Treatment
Surgery
Conservative
Young patient, women seeking pregnancy, cysts >3cm in diameter
Surgical excision, Laser
Radical/Definitive surgery
Hysterectomy and BSO

25. Endometriosis Treatment
Certainty of diagnosis
Severity of symptoms
Extent of the disease
Fertility
Age
Damage to other organs

26. Endometriosis and Infertility
Ovarian function
Tubal function
Coital function
Sperm function
Early pregnancy failure

27. Adenomyosis Endometrial glands deep within the myometrium
Unknown etiology
Different type of patient and presentation

28. Adenomyosis Multiparous women Late thirties or early forties
Sever spasmodic dysmenorrhea
Menorrhagia
Bulky uterus
Diagnosis often histological on examination of hysterectomy sample

29. Adenomyosis Treatment
Induce amenorrhea
Symptoms recur once treatment is stopped
Hysterectomy is the only definitive treatment