2. ,, Presence of functioning endometrial glands and stroma outside their usual location ( the uterine cavity) ”.

3. Genital location : - uterine endometriosis (= Adenomyosis) - extra- uterine endometriosis ( ovaries, fallopian tubes, cervix, vagina, perineum, rectovaginal septum, uterosacral ligaments, cul-de-sac). Extra- genital location ( urinary tract, the bowel the sigmoid colon, the rectum, the umbilicus)

6. Age: common in reproductive period Incidence : 3 – 10 % of the woman aged 20 – 45 Is more common in the higher socio- economic groups and among single woman or women who marry late and have few or not children.

7. Retrograde menstrual flow Vessel spread Direct extension or lymphatic transportation The development of embryonic cell rests Genetic and immunologic influences

8. The ectopic endometrium responds to the cyclic secretion of E and P by proliferating and by bleeding at the time menstruation occurs. The peritoneum reacts forming adhesions The ectopic endometrium forms a miniature cyst (,, chocolate cyst” )

10. Dysmenorrhoea Pelvic pain Dyspareunia Infertility Other signs ( irregular menses, cyclic rectal bleeding, hematuria)

11. History ( symptoms) Pelvic examination - nodularity of the Douglas pouch and uterosacral ligaments - tenderness of the uterosacral ligaments - endometriomas or ’’chocolate chist” of the ovaries - fixed retroverted uterus Investigations (CA-125) Laparoscopy

12. It permits a “see and treat” approach, although its effectiveness may be limited by the nature of the disease and the surgeon's skill. Endometriosis May Appear Brown Black (“Powderburn”) Clear (“Atypical”)

15. Pelvic inflammatory disease Ovarian tumours ( metastatic carcinoma) Bowel cancer Calcified mesotheliomas

16. Consideration STAGE ENDOMETRIOSIS STAGE ENDOMETRIOSIS  Stage I (minimal)  Stage II (mild) : small surface nodules, no adhesion, no clinical signs (except infertility) Electrocautery or CO2 laser  Stage III (moderate): small scattered surface lesions, ovarian endometriomata < 2,5 cm, symptoms often present Electrocautery or CO2 laser, hormonal treatement, conservative surgery  Stage IV (severe) : ovarian endometriomata > 2,5 cm, marked adhesions, cul-de-sac obliteration, symptoms and signs present Conservative surgery, hormones or radical surgical approach  Stage V( very severe) Surgery and hormonal therapy

17. Oral contraceptives Danazol: 400- 800 mg daily, 6 months. Progestogens GnRH agonists

18. It is indicated in moderate to severe disease Conservative surgery Radical surgery ( total abdominal hysterectomy and bilateral salpingo- ooforectomy)