Endometriosis – Stri Roga, Gynecology | Live veda

Endometriosis

Presence and growth of functional endometrial tissue (gland & stroma) outside the uterine cavity.

Sites - It occur anywhere in body

Common sites - Ovaries, Fallopian tubes
                           POD (Pouch of douglas), Lymph nodes,
                           Uterosacral ligament, Sigmoid colon,
                           Abdominal scar of hysterectomy, CS.

Causes - Exact cause is unclear.
1. Retrograde menstruation
2. Direct implantation over surgical scar sites, vagina, cervix etc.
3. Transfer of endometrial cell to other body parts by lymphatic & vascular system.
4. Genetic factor (inheritance) - Increase incidence in 1st degree relatives.
5. Immunological factors - Normally macrophages removes menstrual debris by        phagocytosis. In endometriosis patient, activated macrophages secrets several factors which promotes growth of endometrial cells over ectopic site.

Pathology - 

Under the action of ovarian hormones there is cyclic growth & shedding of ectopic site endometrium (stroma & glands) also. Periodically shed blood either encysted or cyst becomes tense & rupture.

If encysted - Cyst enlarges with bleeding and serum gets absorbed in between periods so content inside becomes chocolate coloured, called as chocolate cyst (commonly located in ovary).

If rupture - as blood is irritant- dense tissue reaction surrounding the lesion with fibrosis.

Pelvic endometriosis - typical finding-
  • Powder burns (small black dots) seen on uterosacral ligament & POD.
  • Scarring & fibrosis in peritoneum surrounding the implants.

Common Features


1. May be asymptomatic.
2. Dysmenorrhoea - co menstrual dysmenorrhoea
3. Menstrual abnormality - Menorrhagia, premenstrual spotting, epimenorrhagia,                      polymenorrhoea.
4. Infertility
5. Dyspareunia, CPP (Chronic pelvic pain) , Abdominal pain.
6. Related to organ involved - Urinary frequency, dysuria, hematuria.
    Sigmoid colon & rectum - Painful defecation, diarrhea, rectal bleeding. 

Diagnosis 
1. Clinical diagnosis - Symptoms of classical triad of endometriosis (Secondary dysmenorrhoea,                dypareunia, infertility)  increasing.
2. USG, MRI
3. Laprascopy (gold standard)- Confirmation.
'Powder burns' - seen on uterosacral ligament, or
'Match stick spot' on peritoneum of POD, Scarring in the peritoneum surrounding the implants
4. CA-125
5. MCP-1 (Monocyte Chemotactic Protein)
6. Biopsy.
Treatment
Preventive -
 
1. Immediately after D&C or around the time of menstruation avoid tubal patency test.
2. During or shortly after menstruation, avoid PV (per vaginal examination)
3. If family history of endometriosis, encourage to early first conception and complete the        family.

Curative - To minimize pain
                - For fertility
                - to prevent recurrence.

A) Expectant - wait and watch
B) Medical Treatment - For endometrial atrophy - hormone therapy.
                                       By producing Pseudo pregnancy - OCP, progestogens, or
                                                              Pseudo menopause - Danazol, or
                                                              medical oophorectomy - GnRH analogues
C) Surgery - When severe symptoms, unresponsive to hormone therapy.
                      Size > 1cm endometriomas, distortion of pelvic anatomy.
    Laparoscopy - ablation & adhesiolysis, LUNA, Hysterectomy.
D) Combined-
     3-6 months preop. - to decrease of size & vascularity of lesion and
     3 months postop. - to destroy residual lesion.
     Drug - GnRH analogue or Danazol.
E) ART (Assisted Reproductive Technique)

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