CMT06210: Apprenticeship in Obstetrics and

Gynecology

SESSION 10:ENDOMETRIOSIS
DR. GODWIN KATISA
Total Session time 120 minutes

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Learning tasks
At the end of this session, students are
expected to be able to:
Outline epidemiology of endometriosis
Explain aetiology/risk factors of
endometriosis
Outline epidemiology of
endometriosisIdentify cause and risk
factors
Explain clinical features of endometriosis
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Learning tasks...
Establish diagnosis/ provisional and
differential diagnosis of endometriosis
Provide pre-referral treatment of
endometriosis

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Activity: Brainstorming

What is endometriosis?

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Definition
The proliferation and functioning of
endometrial tissue outside of the uterine
cavity

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Epidemiology
Ten to fifteen percent of reproductive-aged
women.
Occurs primarily in women in their 20s and
30s.
Common in nulliparous woman.
Accounts for 20% of chronic pelvic pain.
One-third to one-half of women affected with
infertility has endometriosis.
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Pathophsiology
The ectopic endometrial tissue is
physiologically functional. It responds to
hormones and goes through cyclic
changes, such as menstrual bleeding.
The result of this ectopic tissue is “ectopic
menses,” which causes bleeding,
peritoneal inflammation, pain, fibrosis,
and, eventually, adhesions.

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SITES OF ENDOMETRIOSIS
Common sites
Ovary (bilaterally): 60%.
Peritoneum over uterus.
Anterior and posterior cul-de-sacs.
Broad ligaments/fallopian tubes/round ligaments.
Uterosacral ligaments.
Bowel.
Pelvic lymph nodes: 30%.

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SITES OF ENDOMETRIOSIS
Less Common
Rectosigmoid: 10–15%.
Cervix.
Vagina.
Bladder.

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SITES OF ENDOMETRIOSIS
Rare sites
Nasopharynx.
Lungs.
Central nervous system (CNS).
Abdominal wall.
Abdominal surgical scars or episiotomy scar.
Arms/legs.

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Sites for endometriosis

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Causes
Unknown cause
Theories:
 Retrograde menstruation: Endometrial tissue
fragments are retrogradely transported through the
fallopian tubes and implant there or
intraabdominally with a predilection for the ovaries
and pelvic peritoneum.
 Mesothelial (peritoneal) metaplasia: Under
certain conditions, peritoneal tissue develops into
functional endometrial tissue, thus responding to
hormones.
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Causes cont..
 Vascular/lymphatic transport: Endometrial
tissue is transported via blood vessels and
lymphatics. This can explain endometriosis in
locations outside of the pelvis (ie, lymph nodes,
pleural cavity, kidneys).
 Altered immunity: There may be deficient or
inadequate natural killer (NK) or cell-mediated
response. This can explain why some women
develop endometriosis, whereas others with
similar characteristics do not.
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Causes...
Iatrogenic dissemination: Endometrial
glands and stroma can be implanted
during a procedure (eg, c-section).
Endometriosis can be noted in the anterior
abdominal wall.

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Risk factors

Nulliparity
Age > 25 years
Family history
Obstructive anomalies of the genital tract

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Activity 2: Brainstorming

What are clinical features Endometriosis?

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Clinical features
CLINICAL PRESENTATION:
• Pelvic pain (that is especially worse during menses, but can
be chronic):
• Secondary dysmenorrhea (pain begins up to 48 hr prior to
menses).
• Dyspareunia (painful intercourse) as a result of implants on
pouch of Douglas; occurs commonly, with deep penetration.
• Dyschezia (pain with defecation): Implants on rectosigmoid.
• Infertility- 30-40%
• Intermenstrual bleeding.
• Cyclic bowel or bladder symptoms (Haematuria)

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 Clinical features cont.…
SIGNS:
 Fixed retroflexed uterus, with scarring posterior to
uterus.
 Tender uterus or presence of adnexal masses.
 Nodular” uterosacral ligaments or thickening and
indurations of Uterosacral ligaments.
 Ovarian endometriomas: Tender, palpable, and freely
mobile implanted masses that occur within the
ovarian capsule and bleed. This creates a small
blood-filled cavity in the ovary, classically known as a
“chocolate cyst.”
 Blue/brown vaginal implants (rare).
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Activity 3: case study
A 31-year-old woman presents at the gny clinic
with a 4year history of inability to conceive
despite unprotected sex. Her menses began at
age 12 and occurs every month. She complains
of severe monthly pain 1 week before each
menses and pain with intercourse. She denies a
history of sexually transmitted diseases and she
has no history of abormal vaginal discharge. Her
husband has a child from a previous marriage.
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Activity 3: case study...

1. What are the differential diagnoses?

2. How will you confirm the diagnosis?

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Differential diagnosis

Chronic Pelvic inflammatory disease

Uterine fibroid
Adenomyosis

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Diagnosis
History

Pelvic examination

Laparoscopy or laparotomy: Ectopic

tissue must be biopsied for definitive
diagnosis.

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Treatment
Pre-referral treatment will include:
• Analgesics: Non steroidadal anti-
inflammatory e.g diclofenac 50mg 8
hourly
• Oral contraceptives (OCPs)
At the hospital

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Treatment cont…
At the hospital
Medical (temporizing).
 The primary goal is to induce amenorrhea and cause
regression of the endometriotic implants.
 All of these treatments suppress estrogen:
 Gonadotropin-releasing hormone (GnRH) agonists
(leuprolide): Suppress follicle-stimulating hormone
(FSH); create a pseudomenopause.
 Depo-Provera (progesterone [+/– estrogen]): Creates a
pseudopregnancy (amenorrhea).
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Treatment cont…
 Danazol: An androgen derivative that suppresses
FSH/luteinizing hormone (LH), thus also causing
pseudomenopause.
 Oral contraceptives (OCPs): Used with mild
disease/symptoms.
Surgical
 Conservative (if reproductivity is to be preserved):
Laparoscopic lysis and ablation of adhesions and
implants.
 Definitive: Total abdominal hysterectomy and
bilateral salpingo-oophorectomy (TAH/BSO).
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Complications

Due to adhesions may lead to:

Infertility

Chronic pelvic pain

Intestinal obstruction

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Key points
1. Endometriosis is one of the common
gynaecological condition and often
diagnosed as pelvic inflammatory disease

2. Is a common cause of chronic pelvic pain

and infertility

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Key points cont…
1. Diagnosis depend on history, pelvic
findings and Laparoscopy or
laparotomy: Ectopic tissue must be
biopsied for definitive diagnosis

2. Definitive treatment is Total abdominal

hysterectomy and bilateral salpingo-
oophorectomy

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Evaluation
1. What is endometriosis?

2. Mention clinical features of

endometriosis?

3. What are the differential diagnoses for

endomtriosis?

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References
 D.C Dutta. Textbook of Gynecology. 6th
edition
 Obstetrics & Gynaecology, Beckmann.
 Hacker & Moore’s Essentials of Obstetrics
& Gynaecology.
 Current diagnosis & treatment, Obstetrics
& Gynaecology.
 Gynaecology By Ten Teachers, 18th
edition.
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