Endometriosis

Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

 Presence of active functioning
endometrial implants outside its normal
place i.e uterine cavity
 Incidence:20-25% in reproductive age
group

Implantation theory :
Sampson's pioneering work in 1922 attributed endometriosis
to reflux of menstrual endometrium through the fallopian
tubes. Occurrence of scar endometriosis following classical
caesarean section, hysterotomy, myomectomy and episiotomy
further supports this view.
Coelomic metaplasia theory :
Meyer and Ivanoff (1919) propounded that endometriosis
arises as a result of metaplastic changes in embryonic cell
rests of embryonic mesothelium. Hormonal stimulation of
Embryologically similar tissues to the Mullerian ducts.
Metastatic theory :
Suggested by Halban et al. (1924) that embolization of
menstrual fragments through vascular or lymphatic
channels, explain its occurrence at less accessible sites
like the umbilicus, pelvic lymph nodes, ureter,
rectovaginal septum, bowel wall, and remote sites like
the lung, pleura, endocardium and the extremities.

Hormonal influence : The initial genesis of
endometriosis, its further development depends on the
presence of hormones, mainly oestrogen. Pregnancy
causes atrophy of endometriosis through high
progesterone level. Regression also follows oophorectomy
and irradiation. Endometriosis is rarely seen before
puberty and it regresses after menopause. Hormones with
antioestrogenic activity also suppress endometriosis and
are used therapeutically.
Immunological factor : The peritoneal fluid in
endometriosis shows the presence of macrophages and
natural killer (NK) cells. Impaired T cell and NK cell activity
and altered immunology.
Other factors : Genetic - familial tendency reported in
15% cases, multifactorial, vaginal or cervical atresia which
encourage retrograde spill. Prostaglandins.

Uterine :
Uterine : (50%)(50%)
Adenomyosis
-Extra uterine :
Ovary 30%
-- Ovaryperitoneum 10%
Pelvic 30%
-- Pelvic peritoneum
F. tube
-10%
Vagina
- F. tube
-Bladder & rectum
-- Vagina
Pelvic colon
--Bladder & rectum
Ligaments
- Pelvic colon
- Ligaments

endometriosis :
(1) ovary
(2) cul-de-sac
(3) uterosacral
ligaments
(4) broad ligaments
(5) fallopian tubes
(6) uterovesical fold
(7) round ligaments
(8) vermiform
appendix
(9) vagina
(10) rectovaginal
septum
(11) rectosigmoid
colon
(12) caecum
(13) ileum
(14) inguinal canals
(15) abdominal scars
(16) ureters
(17) urinary bladder
(18) umbilicus
(19) vulva
(20) peripheral sites

- Pelvic
- Extra pelvic
Umbilicus.
Scars (Lap.).
Lungs & pleura.
Others.

Early lesions appear papular and red vesicles are filled with
haemorrhagic fluid with surrounding flame-like lesions.
Over time, these vesicles change colour and endometriotic
areas appear as dark red, bluish or black cystic areas
adherent to the site. Scarring in the endometriosis makes it
puckered. Atypical lesions such as non-pigmented areas or
yellowish-white thick plaques have been noticed, which are
healed lesions. Powder burnt areas are the inactive and old
lesions seen scattered over the pelvic peritoneum.
Chocolate cysts of the ovaries represent the most important
manifestation of endometriosis. To the naked eye, the
chocolate cyst shows obvious thickening of tunica albuginea,
and vascular red adhesions are well marked on the
undersurface of the ovary. The inner surface of the cyst wall
is vascular and contains areas of dark brown tissue. The
chocolate cyst lies in the ovary and adherent to lateral pelvic
wall.

ADENOMYOSIS  GROSS SPECIMEN

MICROSCOPIC View of endometriosis interna (ADENOMYOSIS)s

2
1

3

HISTOPATHOLOGICAL IMAGES
OF
1 ENDOMETRIOSIS,
2 OVARIAN ENDOMETRIOMA,
3 SECRETORY ENDOMETRIOSIS

On History
Common symptoms :
Chronic pelvic pain, worsening dysmenorrhea,
acquired dyspareunia, infertility, premenstrual
spotting, dyschezia.
Risk factors :
First degree relative affected, short menstrual
cycles, long duration of menstrual flow, low parity,
infertility, fair complexioned, reproductive tract

Examination

On bimanual pelvic examination, fixed retroverted uterus,

bilateral pelvic tenderness, fixed or enlarged ovaries and painful

uterosacral nodularity.

Deeply infiltrating nodules are most reliably detected when

clinical examination is performed during menstruation.

Adenomyotic uterus is seldom > 12 weeks, soft, smooth & tender

in contrast to fibroid uterus. Isolated adenomyoma can be

differentiated by presence of localised tenderness

Investigations
 Laparoscopy: Gold standard It should not be
performed within 3 months of hormonal
treatment to prevent under diagnosis
 Ultrasound: Ultrasound has a limited role,
however the addition of colour doppler claims
to increase the sensitivity to 91.8%, specificity
of 91.3%
 MRI –useful
 Ca 125-Maybe elevated in severe

Histological Confirmation:

Visual inspection is usually adequate but

histological confirmation of at least one lesion is

ideal.

In cases of ovarian endometrioma >3 cm in

diameter and in deeply infiltrating disease,

histology is a must to rule out malignancy.

Laparoscopy (Sensitivity : 97%, Specificity 95%)
Types of lesions on laparoscopy:
Powder burn or black lesions
White opacified peritoneum
Glandular excrescences
Flame like red lesions
Peritoneal pockets or windows
Clear vesicles
Yellow brown patches
Unexplained adherence of ovary to peritoneum of
ovarian fossa
Encysted collection of thick chocolate coloured or
tarry fluids
Adhesions to posterior lip of broad ligaments/other

LAPROSCOPIC IMAGES :
A  OLD ENDOMETRIOSIS (Blue/Grey) B  OLD ENDOMETRIOSIS (Red)
C  OLD ENDOMETRIOSIS (Brown) D  ACTIVE ENDOMETRIOSIS (Black)

Sonographic Features :

Endometritic cysts (oval or round)- capsulated, fine

homogeneous, uniform, granular echoes,

anechoic, single or multiple, unilateral or bilateral

On Doppler: no vascularity within the mass

Ovarian adhesions to uterus

Free floating fimbria on sonosalpingography

 Several Proposed Schemes
 Revised AFS System: Most Often Used
 Ranges from Stage I (Minimal) to Stage IV (Severe)
 Staging Involves Location and Depth of Disease,
Extent of Adhesions

Revised American Fertility Society Classification of endometriosis 1985
Patient's name Age Date
Stage I (Minimal) Score 1-5 Laparoscopy/Laparotomy/Photography
Stage II (Mild) Score 6-15 Recommended treatment
Stage III (Moderate) Score 16-40
Stage IV (Severe) Score > 40
Total Prognosis
Peritoneal endometriosis <1 cm 1-3 cm >3 cm
Superficial 1 2 4
Deep 2 4 6
Ovarian endometriosis <1 cm 1-3 cm >3 cm Right/Left side separate points
Superficial 1 2 4
Deep 4 16 20
cul-de-sac obliteration Partial Complete
4 40
Ovarian adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
Flimsy 1 2 4
Dense 4 8 16
Tubal adhesions <1/3 Enclosure 1/3 to 2/3 Enclosure >2/3 Enclosure Right/Left side
separate points
Flimsy 1 2 4
Dense 4 8 16

 Age.
 Symptoms.
 Stage.
 Infertility

 Recognize Goals:
– Pain Management
– Preservation / Restoration of Fertility
 Discuss with Patient:
– Disease may be Chronic and Not
Curable
– Optimal Treatment Unproven or
Nonexistent

 Management of Endometriosis must be ‘tailor

made’ taking into account, patients profile,

presenting symptoms, impact of the disease and

effects of treatment on day to day life.

 Empirical treatment of pain symptoms without
definitive diagnosis of endometriosis, a
therapeutic trial of hormonal drug to reduce
menstrual flow is appropriate.
 Medical Therapy for endometriosis can be used
either as primary therapy or in conjunction with
surgery preoperatively or postoperatively-
Sandwich Therapy

 How effective are NSAIDS in treating
endometriosis associated pain?
There is inconclusive evidence to show whether
NSAIDS are effective in managing pain caused by
endometriosis
Advantages:
Not operator dependent
Less expensive
No surgical/anesthetic risk
No post- op adhesion formation
Disadvantages:
Prolonged treatment
Gastric ulceration
Temporary relief

• GnRH analogues: creates a pseudo menopausal
state
• Advantages:
• Reduction in pelvic vascularity and inflammation
• Reduction in size and activity of endometriotic
implants
• Reduction in ovarian cyst diameter
• Reduction in cyst wall diameter
• Disadvantages:
• Hypoestrogenic state
• Bone loss(can be controlled by add back regimen-

 Danazol: pseudomenopausal state
Inhibits ovarian steroidogenesis, decreases
pulsatile GnRH release, decreases
gonadotrophins-antioestrogenic,
antiprogestogenic, androgenic effects
Dosage: 400mg/day
Efficacy: crude pregnancy rate 28-47%

 Progesterone:- Pseudo pregnancy (Kristner’s
Regime) state.
Acts by decidualisation and atrophy of the estrogen
dependent endometriotic foci
Common progesterones : Medroxy progesterone
acetate, norethesiterone, dydrogesterone,
DMPA - cost effective, readily available, 66%
complete resolution
LNG-IUS(Mirena) reduces endometriosis associated
pain(symptom control over 3 years)
Side effects : Irregular Bleeding, weight gain, fluid
retention, breast tenderness, mood changes,

 Gestrinone: Androgenic, progestogenic and

antiestrogenic

 Dosage: 1-25-2-5mg biweekly

 Side effects : similar to danazol

Combined OC Pills:

 To reduce the frequent prolonged bleeding not

recommended in infertile endometriotic women.

 However COCs are the only effective prophylaxis

in against endometriosis.

 RU 486: antiprogestogenic activity with minimal or
no other endocrinologic effects
 Aromatase Inhibitor: Acts on the diseased
endometriotic implants to decrease local oestrogen
production-to inhibit the growth of implants.
 Interferons: combination with GnRH have resulted
in higher cumulative pregnancy rates and monthly
fecundity rates
 SERMs: Selective antiestrogenic activity on the
endometrium, agonist activity on bones and

1997; Rice, 2002; Valle et al., 2003; Donnez et al., 2004;
Crosignani et al., 2005; Schlaff et al., in press)

Agent Dose Route Dosing frequency Common side effects
Combined 30–35 μg Oral Daily (cyclic or continuous) Irregular bleeding,
oral ethinyl weight gain, bloating,
contraceptives estradiol, breast tension and
plus headache
progestin
Danazol 400–800 Oral Daily (duration limited to Androgenic/anabolic
mg 6 months by side effects) (weight gain, fluid
retention, breast
atrophy, acne, oily
skin,
hot flashes and
hirsutism)
GnRH (Duration limited to 6
agonists months
due to BMD effects)
Leuprolide 1mg/day SC daily Hypoestrogenic (hot
injection flashes, vaginal
dryness, emotional
lability, loss of libido
and BMD decline)
Leuprolide 3.75mg IM Monthly
depot 11.75mg IM Every 3 monthly

Agent Dose Route Dosing frequency Common side effects
Triptorelin 3mg IM Monthly
Triptorelin 11.25mg IM Every 3 monthly
depot
Goserelin 3.6mg SC Monthly
Buserelin 300- Intranasal Tds
400µg
Naserelin 200- Intranasal Bd
400µg
Progestins Irregular bleeding
bloating weight gain
and edema
Dydrogestero 60mg Oral 12 days per cycle
ne
Gestrinone 2.5-5mg Oral Daily
Megestrel 40mg Oral Daily
acetate
Norethindrone 5mg Oral Daily
acetate
MPA 30mg Oral daily
DMPA-150 150mg IM Every 3 months

Indications:
Mild Endometriosis associated with
infertility
Endometrioma >4 cm in diameter
Endometriosis of rectovaginal septum or
rectal wall
Failed Medical therapy
Intolerable side effects of medical therapy
Endometriosis with other surgically
correctable infertility factors

 Pre operative assessment: MRI or Ultrasound with

or without IVP, Barium enema, sigmoidoscopy

 Preoperative and post-op medical management:

GnRh-a like goserilin for 3 months preoperatively

reduces the size and AFS score.

Postoperative therapy gives longer period of

remission.

 Primary operation is the best opportunity

 Best outcome by excision of the lesion

 Complete excision has lowest recurrence of

19%

 Adhesions require excision rather than

simple division

 Electrosurgical instruments are used for excision
of endometriotic focii pelvic peritoneum, however
the depth of dissection is unpredictable & hence
damage to gut.
Sophisticated energy sources available are:
1. Carbon dioxide or Nd YAG laser: Allows
vaporisation; excision; high cost
2. Harmonic scalpel: Ultrasound mechanical source,
for cutting and coagulation
3. Argon beam: for widespread superficial lesion
4. Helica thermal coagulator: effective in
vaporisation with risk of thermal damage.

Surgery when pain relief is the priority:
 Early stage disease: LUNA along with ablation of
endometrial deposits improves outcome
 Moderate to severe disease: Removal of the entire
lesion recommended
Endometrioma:
1. For large unilateral endometrioma-
salpingoopherectomy of the affected side;
2. Bilateral large endometrioma: <40years: ovarian
tissue to be conserved as far as possible
3. Insufficient evidence to justify use of pre op or
post op hormones
4. HRT recommendation after bilateral
salpingooherectomy is controversial

Surgery when infertility is the priority
 Early stage disease: Laparoscopic excision or
ablation with adhesiolysis
 Moderate to severe endometriosis: role of surgery
is uncertain(overactive excision may reduce
fertility)
 Endometrioma: laparosopic cystectomy better
than drainage and coagulation.
Post op hormonal treatment has no beneficial effect
on pregnancy rates after surgery
Tubal flushing improves pregnancy rates.

 Treatment with IUI improves fertility in minimal to
mild endometriosis
 IVF appropriate especially when tubal function is
compromised, if there is male factor infertility
and/or other treatments have failed.
 Treatment with GnRH agonists for 3-6months
before IVF increases the rate of clinical
pregnancies
 Laparoscopic ovarian cystectomy is recommended
for endometriomas >4cm in diameter.

Endometriosis

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Endometriosis