ENDOMETRIOSIS
DEFINITION
The presence of endometrial tissue outside the
normal uterus cavity.
Endometriosis is Classified Into:
Internal type (Adenomyosis): the presence of
endometrial tissue in the muscle of the uterus
External type: the presence of endometrial tissue
outside the uterus or serosal involvement from without
INCIDENCE
Increased in recurrent years due to increased
awareness about the disease and availability of
laparoscopy as diagnostic tool.
PREDISPOSING FACTORS
1. Age - between 30 - 40 years old
2. Parity - 50 - 700k develop in nullipara
3. Estrogen - estrogen may play role in endometriosis
4. Genetic factor - it is common in certain families and
in Japanese
5. Socio-economic - it is a disease of rich people
6. Cervical stenosis and RVF
7. Immunological factors - immunological defect (cellular mediated
type)
CAUSES OF ENDOMETRIOSIS
1. Retrograde Menstruation (Sampson's theory) Endometriosis is
common with cryptomenorrhea against this theory - endometrium,
menstruation is non-viable and it can not explain distant
endometriosis.
2. Serosal Metaplasia (Meyer's theory)
The female genital tract develops from mullerian due
which develop from coelomic epithelium. Endometriosis
develop from dormant embryonic cells is differentiated into
endometrial cells as a result of inflammatory or hormonal
stimuli.
Against this theory, it can not explain endometriosis outside
pelvis and abdomen, also endometriosis never develop in
absence, normal endometriosis.
3. Lymphatic Spread (Halban's Theory)
This theory can explain endometriosis, pelvic LN.
*
Endometriosis of the umbilicus (spread along
lymphatic of the urachus)
*
Endometriosis of the kidney (spread along
periureteric lymphatic
4. Diverticular Theory (Cullen's theory)
The basal layer of endometriosis grow downwards into
myometrium. It is separated from original gland due to uterine
contraction. This theory explains adenomyosis, but not
endometriosis.
PATHOLOGY OF ENDOMETRIOSIS
I. Type (Adenomyosis)
* Uterine
The uterus symmetrically enlarged but does not exceed 10-12 weeks
gestation
The wall is thick due to myohyperplasia
Islands of endometrial tissue can be seen scattered
throughout the myometrium. They are surrounded with well differentiated
stromal cells
* Types:
non-functioning type
functioning type (rare) small chocolate cysts are scattered through
out the myometrium
II. Extrauterine
A. Pelvic
*
Ovaries - the most common site to be affected.
It is usually bilateral. It takes the form of multiple
burnt match head a tarry cyst (chocolate cyst) which
is variable in sizes, the wall is thick, granular and
surrounded by extensive adhesion
*
Serosal surface of the uterus is bickered with multiple small
haemorrhagic nodules
*
Broad ligament, uterosacral and ovarian ligament
*
Vesico-uterine Pouch and Pouch of Douglas
*
Fullterm
*
Frozen pelvis
B. Extra Pelvic
Vulva and vagina in the posterior fornix, RV
septum, episiotomy scar
Abdominal wall: umbilicus or laparotomy scar
Gastro-intestinal tract - caecum, appendix, rectum, rectosigmoid junction
Urinary tract - kidney and ureteric
Pleura and lung
CLINICAL PICTURE SYMPTOMS
1. Pain
* Dysmenorrhoea - congestive dysmenorrhoea pain occurs 2 3 days before the onset of menses due to pelvic congestion,
increased after the flow, reaches its maximum in the last day
of menses pain is due to pressure if imprisoned blood
* Dyspareunia - due to endometriosis of post fornix - RV
septum = RVF
* Pain during defecation - endometriosis in posterior fornix,
RV septum
* Acute Abdomen - rupture tarry cyst
2. Menorrhagia
Increased surface area of endometrium
increased vascularity
Endometrial hyperplasia
3. Infertility in 30 - 40% of cases
a. Tubal - pelvic adhesions which interfere for
with ovum pick up and transport
Increased PG content of peritoneal fluid
B. Ovarian - Anovultion
LPD - due to tutolytic action of PG
C. Uterine - production of autoantibodies
unfavourable for implantation
d.
e.
f.
Peritoneal - macrophages --> phagocytic sperm
Hyperprolactinaemia
Early spontaneous abortion
Examination
general examination
abdominal examination: -ve or endometriosis of umbilicus
local examination:
endometriotic nodule of ovulation
endometriotic nodule of recto-vaginal septum
uterus symmetrical enlarge or fixed r.v.f.
investigations
1. infertility investigation
2. laparoscopy:
*
confirm the diagnosis
*
localize and evaluate the extent of
lesion
*
localize and evaluate the extent of
adhesion
second look laparoscopy at the end of
treatment
*
therapeutic vulva and lysis of adhesion
3.
4.
5.
6.
biopsy from skin or vulva lesion
curettage in case of menorrhagia
sigmoidoscopy - git lesion
cystoscopy - urinary lesion
Treatment of Endometriosis
General Measure
1. get pregnant as early as possible
2. sedative and analgesic
3. iron, vitamin, tonic
Hormonal Treatment
I. Induction of Pseudomenopause
Aim
- stop cyclic stimulation of endometrium + atrophy Danazol - 17
alpha ethyl testosterone derivative
1. It acts on the hypothalamus and inhibit release of GnRH
2. Inhibit release of pituitary Gn
3. Inhibition of ovarian steroid genesis
4. Amenorrhoea
5. Dose 200 - 800 mg - 6 months
Side effects - acne-hirsutism, weight gain
LH-RH - continuous administration of LH-RH result initial
stimulation followed by down regulation (decrease number
of receptor) and desensitization (decrease responsiveness)
of pituitary gland
* Inhibition of release pituitary gland
* Inhibition of ovarian steroidogenesis * Amenorrhoea
Dosage - 4 mg microcapsule 1M monthly 3 - 6 months Side
effect - expensive, osteoporosis
Androgen - testosterone and methyltestosterone Dose: 5 10 mg/day 3 - 6 months
II. Induction of Pseudo Pregnancy
Progesterone - 10 gm/day ---> which increased up to 40
mg/dl
Medroxy progesterone acetate
SURGICAL TREATMENT
1. Conservative
Resection of endometriotic ---> lysis of adhesion
Ventrosuspension of uterus
Micro-surgical technique
Corticosteroid, antihistamine - postoperative given
2. Laser (Xray) - used through the laparotomy or laparoscopies for
photocoagulation of endometriotic implant
3. Radical
T AH + SSO + Resection of endometriosis
Combined Treatment
Hormonal treatment followed with surgery
Radiological Treatment
It is indicated when the operation is risky due to extensive
adhesion or endometriosis of recto vaginal septum
It is due to deep x-ray therapy or packing of the uterine cavity
with radium. It is rarely done.
Chronic Pelvic pain and Endometriosis
"Symptoms that depress the doctor". One of these was
entitled "Too much pain".
Many studies have confirmed that people complaining of
chronic pain are more likely to have a neurotic type of
personality. Pain has often been found to be a sign of
psychological illness and there is no doubt that most patients
with chronic pain who present to hospital show evidence of
psychological disturbance.
Pain is caused by a condition which has proved resistant to
attempts at a cure, the doctor's concern may be increased
by feelings of failure and inadequacy. Such is the case with
advanced malignant disease.
Chronic pelvic pain is a common complaint amongst women
in their reproductive years. In addition investigation of pelvic
pain was the commonest indication for laparoscopy.
Severe pain is not necessarily caused by organic disease whilst
conversely less troublesome pain may be the harbinger of serious
pathology. Pain may of course be related to a nongynaecological
problem.
Table 15.1 Gynaecological Causes of Chronic Pelvic Pain
1. Cyclical pain: Dysmenorrhoea
Mittelschmerz
2. Chronic pelvic inflammatory disease
3. Endometriosis
4. Neoplasia:
Benign - fibroids
- ovarian cyst
Malignant disease of the genital tract
5. Pelvic venous congestion I pelvic pain syndrome
(PPS)
6. Polycystic ovarian syndrome
7. Residual ovary syndrome
8. Uterovaginal prolapse
Table 15.2 Non-gynaecological causes of chronic
pelvic pain
Intestine:
Diverculitis
Inflammatory bowel disease
Irritable bowel syndrome
Malignancy
Subacute intestinal obstruction
Urinary tract:
Calculus
Chronic retention
Infection
Malignancy
Musculo-skeletal:
Lumbo-sacral osteoarth ritis
Prolapsed intervertebral disc
Spondylolisthesis
INNERVATION
Gynaecological pain may be somatic, from the vulva,
perineum and lower vagina, and transmitted via the
pudendal nerves (S2, 3 and 4) or visceral from the uterus,
fallopian tubes, ovaries and visceral peritoneum supplied by
the autonomic nervous system. Visceral and somatic pain
perceptions are different. The viscera are insensitive to
thermal and tactile.
Referred pain results from irritation of the overlying
peritoneum, and is perceived in dermatomes supplied by the
same nerve root.
Stimuli that produce pain include the following:
1. Distension and contraction of a hollow organ
2. Rapid stretching of the capsule of a solid organ
3. Chemical irritation of the parietal peritoneum
4. Tissue ischaemia
5. "Neuritis", secondary to inflammatory, neoplastic or
fibrotic processes in adjacent organs
Characteristics of the Pain:
1. Mode of onset
2. Duration
3. Site
4. Radiation
5. Relationship to menstrual cycle and previous pregnancy
6. Intensity: this can be best assessed by instructing the
patient in the use of a visual analogue scale
EXAMINATION
The formal examination should cover the following points:
1. General examination, specifically looking for signs of malignancy
such as lymphadenopathy, anaemia and swelling of the lower
limbs.
2. Abdominal palpation for masses, ascites and tenderness.
Vaginal examination:
3. Speculum examination Bimanual palpation
4. Rectal examination, to exclude malignant disease
5. Examination of lumbo-sacral spine and hip joints
GYNAECOLOGICAL CONDITIONS
Cyclical Pain
Dysmenorrhoea is a common complaint, although only in
5%. In the majority of cases there is no underlying
pathology although congestive dysmenorrhoea is said to be
associated with such conditions as endometriosis or
adenomyosis. Ovulation Pain (Mittelschmerz) mid-cycle is of
acute onset and is a sharp lower abdominal pain by several
hours of dull aching in the pelvis. Caused by rupture of the
ovarian follicle at ovulation, the onset of pain corresponds to
the peak LH levels 24 hours prior to ovulation perifollicular
smooth muscle, mediated through prostaglandin.
PELVIC INFLAMMATORY DISEASE (PID)
Clinical signs and symptoms are frequently misleading
however. In women who have a combination of lower
abdominal pain, vaginal discharge and pelvic tenderness
only 600k will be found to have pelvic infection at
laparoscopy.
ENDOMETRIOSIS
The pain of endometriosis is variable in presentation
and there is a poor correlation with the laparoscopic findings.
Severe pain may be associated with minimal disease, whilst
the reverse is also true. The commonest symptoms are
dysmenorrhoea, dyspareunia and persistent dull ache in the
pelvis, although severe acute pain may be caused by the
rupture of an endometriotic cyst.
NEOPLASIA OF THE GENITAL TRACT
Benign
Large fibroids may cause a persistent dull aching pain in the
pelvis, whilst an ovarian cyst may produce recurrent
episodes of sharp pain secondary to torsion of the ovarian
pedicle.
Malignant
Although pain is not a leading feature of malignant disease
of the cervix and body of the uterus, lower abdominal and
pelvic pain is the commonest presenting symptom in
advanced ovarian cancer.
Pelvic Pain Syndrome (PPS)
Dull aching pain with occasional severe acute attacks more
commonly present in the right iliac fossa, but sometimes moving
from one side to the other.
Polycystic Ovarian Syndrome (PCOS)
It has been postulated that the excess oestrogen seen in
PCOS causes dilatation of the pelvic veins (Reginald et al
1989), as oestrogen has been shown to inhibit the
contraction of smooth muscle in the walls of human veins.
Residual Ovary Syndrome
Symptoms from ovaries left at the time of hysterectomy.
Chronic pelvic pain and dyspareunia are the presenting
symptoms in approximately 75% of cases.
Uterovaginal Prolapse
A dull aching pain or dragging sensation in the pelvis in association
with a "lump" in the vagina.
NON-GYNAECOLOGICAL CONDITIONS
Gastrointestinal
Diverticular disease is common in people over the age of 60
years and approximately half the patients have chronic or
intermittent lower abdominal pain. Constipation, or alternating
diarrhoea and constipation with passage of pebbly stools
may accompany the pain or occur independently.
The irritable bowel syndrome (TBS) is a common complaint
of women presenting with pelvic pain to a Gynaecology
clinic.
Renal Tract
Causes of pain arising from the urinary tract are infection
and the presence of calculi. Chronic infection can result in
persistent pelvic pain, whilst chronic interstitial cystitis
usually occurs in middle-aged women and causes severe
supra-pubic pain.
Ureteric and Bladder Calculi
May cause recurrent episodes of lower abdominal and
pelvic pain.
Skeletal Causes
Pelvic pain are often polysymptomatic and may well
complain of back-ache. Low back-ache of musculo-skeletal origin
radiates most commonly to the lower limbs and not to the
abdomen or pelvis. Hip pain may sometimes be mistaken for pain
arising in the lower back and characteristically is most severe in the
groins but may also be felt in the buttocks.
INVESTIGATIONS
Laparoscopy
Laparoscopy is by far the most informative and is an
essential part of the investigation in all cases of pelvic pain.
Imaging
Ultrasound
Is a very informative investigation which has the added
advantage of being non-invasive. The dimension of uterus
and ovaries tend to be larger than normal in cases of PPS
whilst the diameter of pelvic veins can be measured using
the Doppler mode.
X-Rays
1. Plain x-ray of lumbo-sacral spine and hip joints
2. Intravenous urogram
3. Barium enema
4. Transuterine pelvic venography
Computerized Tomography and Magnetic Resonance
Imaging Although these techniques have no place in
assessing the majority of women with chronic pelvic pain
they are invaluable in assessing the spread of malignant
disease.
OTHER INVESTIGATIONS
1. Examination of mid-stream urine specimen
2. Full blood count may reveal an iron deficiency which although
commonly caused by menorrhagia, may alert to the possibility of a
colonic malignancy.
TREATMENT
In a minority of women complaining of chronic pelvic
pain a specific pathology can be identified as the cause, and
the appropriate treatment undertaken.
Surgical Treatment
Although surgery clearly has a limited role in a
disorder confined exclusively to the child bearing years,
there have been advocates of this approach. Resection of
dilated ovarian veins has been successful in some cases as
has hysterectomy. In the older woman who has no wish for
further pregnancies, total abdominal hysterectomy together
with bilateral salpingooophorectomy, followed by hormone
replacement therapy will definitely have a place.
Drug Treatment
Continuous High Dose Progestogen
The rationale behind this treatment is to reduce
oestrogen levels by suppressing ovulation. Using
medroxyprogesterone acetate (MPA) (Provera Upjohn) 300
mg/day have achieved promising results.
Dihydroergotamine (DHEl
The use of ergot alkaloids is not a new idea. Over 100 years
ago, Lawson Tait used ergot to relieve the pain of congestive
dysmenorrhoea. DHE is a selective venoconstricting agent
which increases venous tone and mobilizes blood which is
present in capacitance vessels.
PSYCHOTHERAPY
Many of these women are helped by a sympathetic
doctor who is prepared to take their complaint seriously.
2. Full gynaecological, contraceptive and obstetric history,
including any sexual problems.
3. Full history relating to bowel and urinary function.
4. Past medical history, including psychiatric illness.
5. Family history with particular reference to cancer,
amongst female relatives