Endometriosis - Endometriosis is defined as the presence of endometrial glands & stroma outside the endometrial cavity and uterine musculature. The pelvis is the most common site of endometriosis, but endometriotic implants may occur nearly anywhere in the body. Endometriosis is a common gynecologic problem in reproductive-age reproductive women who have : • Pelvic pain, dyspareunia, or • Infertility. - Pathogenesis The implantation theory proposes that : • endometrial tissue desquamated during menstruation passes through the fallopian tubes, where it gains access to and implants on pelvic structures. • The incidence of retrograde menstruation is similar in women with and without endometriosis. Thus, the development of endometriosis could depend on: on 1- the quantity of endometrial tissue reaching the peritoneal cavity, 2- specific factors enhancing attachment of endometrial cells to the peritoneum and ovary, or 3- the capacity of a woman's innate immune system to remove the refluxed menstrual debris. - - The direct transplantation theory : • is the probable explanation for endometriosis that develops in episiotomy, cesarean section, and other scars following surgery. - Haematogeneous or lymphatic spread Theory : • Endometriosis in locations outside the pelvis likely develops from dissemination of endometrial cells or tissue through lymphatic channels or blood vessels. Metapliasia of coelomic epithelium : • The coelomic metaplasia theory proposes that the coelomic (peritoneal) (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue. • This theory is based on embryologic studies demonstrating that all pelvic organs, including the endometrium, are derived from the cells lining the coelomic cavity. - - The induction theory : an extension of the coelomic metaplasia theory, • postulates that the refluxed endometrial debris releases a product that activates undifferentiated peritoneal cells to undergo metaplasia. There is no conclusive conclusive proof that the peritoneum can undergo spontaneous or induced metaplasia. - Immunological theory : ( the 2 most accepted theory ) 1- Deficient eficient cellular immunity results in an inability to recognize the presence of endometrial tissue in abnormal locations. Decreased natural killer cell activity resulting in decreased cytotoxicity to autologous endometrium has been reported in women with endometriosis. endometriosis 2- The presence of increased concentrations of leukocytes and their cytokine products in peritoneal fluid of women with endometriosis may play a role in the initiation and growth of the ectopic implants. Growth factors as : Matrix Metaloprotienases (MMP) , Epidermal growth factors .. Risk Factors : 1- Hormonal Imbalance (Causes Causes of hyperestrogenemia) hyperestrogene stimulate growth rowth of endometrium deposit . 2- Anatomic alternations of the pelvis that increase tubal reflux of menstrual endometrium increase a woman's chance of developing endometriosis. The incidence of endometriosis is increased in young women with genital tract obstructions that prevent expulsion of menses into the vagina and increase the likelihood of tubal reflux. 3- The possibility of a familial tendency for endometriosis has been recognized for several decades. If a patient has endometriosis, a first-degree first female ale rela0ve has a 7% likelihood of being affected similarly. Pathology Macroscopic Appearance : Endometriotic implants have a variety of appearances. A) Pelvic endometriosis : 1- Superficial lesions on the ovarian or peritoneal surface, surface commonly are : - Colour : • Reddish maculae or nodules • Collection of hemosiderin results in yellow-brown yellow or black discoloration (powder-burn burn lesions). • Nonpigmented disease appears as whitish opacified peritoneum, translucent blebs, or pinkish polyploid implants. - Consistency: similar to normal endometrium. - Size: vary from 1 mm to several cen0meters 2- Deep infiltrative lesions : - Endometriosis also may appear as a deeply infiltrative disease. - Tumorlike masses form from invasion, and diffuse fibrosis usually develops in : • Posterior cul-de de-sac, • Pelvic sidewall, • Posterior osterior broad ligament • Ovary • May ay extend deep into the Retroperitoneal space, occasionally constricting the ureter. - Lesions in the cul-de-sac sac may invade the rectovaginal septum. - The rectosigmoid and small bowel may become adherent to these areas. B) Ovarian Endometriosis : 1- Superficial lesions ( see above ). 2- Endometriotic cysts (Endometriomas ) " chocolate cyst" : - Endometriotic foci on the ovarian surface may develop a fibrous enclosure and manifest cyst formation as a result of accumulation of fluid & blood. - Size: several millimeters to over 10 cm in size. - Colour: Bleeding with menses gives the cyst a dark red or bluish hemorrhagic color. The degradation of blood pigment over time results in thick, tarry contents, hence the term chocolate cysts. cysts or Dense ense fibroid adhesions from these cysts to the pelvic sidewall & fallopian tubes are common and may obscure visualization of the cyst. - Lining: Cyst are lined by endometrium - The pressure of enclosed fluid inside the cyst may destroy the endometrial lining , therefore the presence of : Haemosiderin laden cells or stromal cells even in absence of glandular endometrial element, are enough histopathological hist evidence for diagnosing endometriosis ( Main diagnostic procedure of endometrial cyst is Histopathology ) . Microscopic Appearance - Endometriosis is histomorphologically similar to eutopic endometrium. - The four major components of endometriotic implants are : 1- Endometrial glands, 2- Endometrial stroma, 3- Fibrosis 4- Hemorrhage. - The endometrial glands in ectopic implants : • Lack uniform size & shape. • The glands may show normal cyclic change with mitotic figures & pseudostratification in response to estrogen or vacuoles and intraluminal secretion in n response to progesterone. - The stromal cell morphologies of ectopic & eutopic endometrium are similar. • Interstitial hemorrhage with accumulation of blood products and hemosiderin-laden hemosiderin macrophages rophages is a frequent finding. Symptoms - The common signs & symptoms of endometriosis are: are 1- Pelvic Pain 2- Dysmenorrhea 3- Dyspareunia, 4- Abnormal uterine bleeding 5- Infertility. The type and severity of symptoms are dependent on the extent of disease, the location, and the organs involved. Even limited amounts of disease may cause significant symptomatology. - Pain : 6 D causes : 1- Dysmenorrhea 2- Deep pelvic pain ( chronic pelvic pain ) 3- Dull low back pain 4- Dyspareunia 5- Dysuria 6- Dyscasia ( bleeding per rectum ) Acute abdominal pain may result from hemorrhage secondary to a ruptured endometrioma. - Dysmenorrhea is a more frequent complaint than dyspareunia. • 2ry dysmenorrheal star0ng few years after onset of menstruation. • Pain is characterized by crescendo-Decrescendo Decrescendo fashion in which increases during menses due to distension of ectopic endometrial glands,, then decreases gradually toward the end of the cycle due to absorption of blood. - Chronic pelvic pain : • Diffuse or localized chronic pelvic pain ( < 6 months ) is strongly sugges0ve of endometriosis - Dyspareunia is more common in women with invasive endometriotic nodules in : 12345- cul-de-sac, uterosacral ligaments, rectovaginal septum, vagina, associated fixed RVF uterus. - Abnormal uterine bleeding ( 1/3 of women ) • Symptoms : 1- Oligomenorrhea, 2- Polymenorrhea, 3- Midcycle or Premenstrual remenstrual spotting. • Cause : The abnormal bleeding likely results from conditions associated with endometriosis: 1- Oligoanovulatory ligoanovulatory luteinized unruptured follicles, 2- Luteal phase defects, 3- Other associated pathology such as uterine fibroids. Endometriosis involving the gastrointestinal or urinary tracts and extrapelvic sites causes symptoms characteristic of the location of disease. - Bladder involvement is associated with : • Frequency and urgency. • Invasion of the mucosa results in hematuria. • Ureteral and rare cases of renal endometriosis occasionally cause flank pain or gross hematuria. - Symptoms suggestive of gastrointestinal involvement include : • • • • • in decreasing order of frequency, diarrhea, rectal bleeding, constipation, and dyschezia. - There are numerous case reports of extrapelvic endometriosis. 1- Pulmonary endometriosis causes catamenial hemoptysis and dyspnea. 2- Cutaneous lesions are associated with catamenial bleeding, tenderness, and swelling. - Infertility : Endometriosis constitute 70% of cases of infer3lity • Endometriomas and endometriosis with adhesions distort pelvic anatomy and impair tubal ovum pickup, which is an acceptable explanation for infertility. • Subfertility has focused on peritoneal fluid leukocytes and their cytokine products. Studies have suggested that constituents in the peritoneal fluid inhibit sperm function, fertilization, embryonic development, and implantation. Staging Diangosis Laparoscopy : - It's the gold standard for diagnosis of endometriosis - It's indicated in cases of chronic pelvic pain , infertility and unresolved adnexal mass - It shows the macroscopic appearance mentioned above .
