Endometriosis, Fibroids, PCOD
Dr: Salah Ahmed
Endometriosis
- presence of endometrium (glands and stroma) outside the uterine cavity
- occurs in as many as 10% of women in their reproductive years and in nearly half of
women with infertility
- sites: ovaries, pouch of Douglas, uterine ligaments, tubes, rectovaginal septum
(common sites), peritoneal cavity, around umbilicus (less frequent) and lymph nodes,
lungs, and even heart, skeletal muscle, or bone (uncommon)
Pathogenesis:
- Three theories:
1- Regurgitation theory:
- currently the most accepted
- suggests backflow of endometrium through the fallopian tubes during
menstruation with subsequent implantation
- disadvantage: this theory cannot explain lesions in the lymph nodes, skeletal
muscle, or lungs.
2- Metaplastic theory:
- suggests endometrial differentiation of coelomic epithelium
- disadvantage: cannot explain the lesions in the lungs or lymph nodes
3- Vascular or lymphatic dissemination theory:
- has been invoked to explain extrapelvic or intranodal implants
Morphology:
- the lesion contains functioning endometrium, which undergoes cyclic bleeding
- grossly: -red-blue to yellow-brown nodules or implants
- vary in size from microscopic to 1 to 2 cm in diameter
- Often the lesions fuse to form larger masses
- When the ovaries are involved, the lesions may form large, blood-filled cysts
(chocolate cysts)
- complicated by: 1- adhesions (bleeding, organization, fibrosis) which may lead to
tubal obstruction and so to infertility 2- may undergo malignant change
Clinical manifestations:
- depend on the location of the lesions:
1- Extensive fibrosis of the oviducts and ovaries often produces discomfort
in the lower abdominal quadrants
2- Pain on defecation reflects rectal wall involvement
3- dyspareunia (painful intercourse) reflects uterine serosa involvement
4- dysuria reflects involvement of the bladder serosa
- In almost all cases, there is severe dysmenorrhea and pelvic pain as a
result of intrapelvic bleeding and periuterine adhesions
ADENOMYOSIS
- the growth of the basal layer of the endometrium down into the myometrium
- Nests of endometrial stroma, glands, or both, are found down in the myometrium
between the muscle bundles microscopically
- The uterine wall often becomes thickened and the uterus is enlarged as a result of
the presence of endometrial tissue and a reactive hypertrophy of the myometrium
- Because these glands derive from the stratum basalis of the endometrium, they do
not undergo cyclical bleeding
- marked adenomyosis may produce menorrhagia, dysmenorrhea, and pelvic pain
before the onset of menstruation
red-blue to yellow-brown nodules
Endometrial glands and stroma within the myometrium
Fibroids (Leiomyoma)
- Benign tumors that arise from the smooth muscle cells in the myometrium
-They are the most common benign tumor in females and are found in 30% to 50% of
women during reproductive life
- more frequent in blacks than in whites
-Estrogens and possibly oral contraceptives stimulate their growth; conversely, they
shrink postmenopausally
Morphology:
- firm, pale to gray, well-circumscribed lesions
- may be single or multiple , small or large
- location : - intramural (located within myometrium)
- subserosal ( beneath the serosa )
- submucosal (close to endometrium)
- may undergo cystic degeneration, calcification, red degeneration, necrosis,
malignant change
Clinical manifestations:
- may be asymptomatic and be discovered only on routine pelvic or post mortem
examination
- The most frequent manifestation, when present, is menorrhagia, palpable mass
- complication: 1- bleeding 2- reduced fertility 3- malignant change (very rare)
Multiple fibroids (subserosal)
Multiple fibroids (submucosal, intramural)
interlacing smooth muscle fibers and spindle cells in swirling
pattern
POLYCYSTIC OVARIAN DISEASE (Stein-Leventhal syndrome )
- characterized by large ovaries with multiple cysts
- Pathogenesis: 1- genetic factors (autosomal dominant )
2-endocrine factors: high androgens, high LH/FSH ratio (peripheral
conversion of androgens to estrone)
- Morphology: large, gray-white ovaries with multiple subcortical cysts 0.5 to 1.5 cm
in diameter
- Clinical manifestations: - common in young women
- hirsutism, acne (excess androgen)
- menstrual disturbance (amenorrhea, oligomenorrhea)
- anovulatory cycle (secondary to high LH\FSH ratio
- infertility (anovulation)
- obesity leading to increased insulin resistance and
development of type 2 diabetes
Subcortical cysts
Hirsutism
Thank you