CHAPTER I

PREFACE
Endometriosis, one of the most common disease entities confronting gynaecologists, is
defined as the presence of endometrial glands and stroma tissue outside the uterus. The presence
of this ectopic tissue evokesan estrogen dependent chronic inflammatory process. This disease
affects 5% to 10% of women of reproductive age1. Patients may present with pain, subfertility, or
a combination of these problems; the disease may be suspected from pelvic examination or
imaging studies. The primary focus of invetigation and treatment should be directed at resolution
of the presenting symptom. However, because endometriosis is a chronic, relapsing disorder,
clinicians should develop a long term plan of management with each patient that is dependent on
her symptoms and goals for fertility and quality of life. At present there is no consensus on the
cellular or molecular origins of this disease 2. Despite advances in the understanding of
endometriosis, clinicians are still faced with a paucity of rigorous science behind the
management of this enigmatic disorder.

CHAPTER II
CASE REPORT
A Personal Data
Name
Age
Sex
Marital Status
Address
Profession
Religion
Ethnic
Education
Date of Admission
Medical Record Number
B Anamnesis

: Miss.R
: 24 years old
: Female
: Single
: Indonusa Housing Block F No.5 Tanjung Pinang
: Student
: Islam
: Minang
: Senior High School
: 18-10-2016
: 162041

Main reason for visit : palpable lump in the area of the pubic symphysis
Other complainment : (-)
Present History Illness :
A woman 24 years old that come to obstetric and ginecology polyclinic on 18
october 2016 with history of palpable lump in the area of the pubic symphysis since 1
years ago. Then the lump increasingly enlarged and palpable mass solid not have pain the
size of the mass like babys head. Beside that, she have a irregular menstruation period
every 36 days and disminorrhea (-), metorhaggia (-), menarche : 13 years old. LMP : 24 /
09/ 2016.
Other complainments like fever (-), nausea (-), vormittus (-)
Previous Illness History :

There wasnt previous history of heart, lung, liver, kidney, DM, hypertension, and allergy.

Family Illness History :

Theres wasnt history of contagious disease, hereditary and physicological illness in the
family
Physical Examination :
GA Cons BP
PR RR T Body Weight Body Height
Mdt CMC 130/80 81 22 36,7
43 kg
150 cm
Eyes
: Conjunctiva wasnt anemic, Sclera wasnt icteric
Neck
: Tyroid gland no enlargement
2

Chest
: Normal
Abdoment
: Gynaecological record
Genitalia
: Not checked
Extremity
: Edema -/-, Physiological Reflex +/+, Pathological Reflex -/Gynecologic Record :
Abdoment
:
I
: slightly enlarge
Pa
: A smooth solid mass (+),palpable lump in the area of the pubic
symphysis.
Pe
Au

: Tympanic
: Peristaltic sound was normal

USG :
-

Uterine size normal

Look mass with size I : 10 x 9 x 9 cm dan II : 10 x 9 x 9

Diagnosis pre op
Planning

: Ovarium cysts with differensial diagnostic Endometriosis cysts

:
-

Observation general state and vital sign

Consultation to docter Sp.An, Sp.B, and Sp.PD
Advise : preparation Laparotomy

Report of the operation :

-

Inferior midline incision

Exploration, looking gray colored cystic mass of the babys head coming

from the ovarian dextra

Cystic mass looked at the clenched fist of adults originating from the

ovarian sinistra
Impression : bilateral endometriosis cystic
The ovarian sinistra cystectomy performed
Bleeding treated and stitched

Follow Up

VK, 18 October 2016

Mawar post Op, 19 October 2016 at 15.00

S/ no complaints

S/ foot numbness (+), pain post op (+)

O/ Consentration : CM

O/ Consentration : CM
3

P/V (-)

P/V (+) normal

A/ Endometriosis Cysts

A/ Post SOD + cystectomy sinistra a/i bilateral

advice by dr. Indri, Sp.OG :

endometriosis cysts

- Adona 2 Amp

P/ IVFD RL + Tramadol (2 Amp) 28 gtt/i

- Transfusion PRC 1 Kolf

Ceftriaxone 2x1

- confirm to dr. Nuhadi, Sp.Bd

Metronidazole fls 3x1

R/ Laparotomy on date 19/10/2016 at 10.00 Ketorolac 2x1

oclock with dr. Indri, Sp.OG

Transamin 3x1
Vit K 3x1

Mawar, 19 October 2016 at 19.00

Vit C 3x1

Os allergy post transfusion, advise by dr. Indri, Pronalgess sup 2x2

Sp.OG :

Transfusion PRC 1 kolf

-dexamethason Inj 2 Amp/IV

-Stop PRC

Mawar, 20/10/2016

BP : 100/80

S/ flatus (+), allergy post transfusion (+),

HR : 78

leukorrea (+)
O/ Cons : CM, BP : 110/70, HR : 89, RR : 22,

Mawar, 21/10/2016

T : 36,9

S/ no complaints

A/ Post SOD + Cystectomy Sinistra a/i

O/ Cons : CM, BP : 11/70, HR : 80,

Endometriosis Cysts

RR : 20, T : 36,5

P/ IVFD RL + Tramadol (2 Amp) 28 gtt/i

A/ Post SOD + Cystectomy Sinistra a/i Ceftriaxone 2x1

Endometriosis Cysts

Metronidazole fls 3x1

P/ - IVFD RL + Tramadol (2 Amp) 20 gtt/i

Ketorolac 2x1

-Ceftriaxone 2x1

Transamin 3x1

-Metronidazole fls 3x1

Vit K 3x1

-Ketorolac 2x1

Vit C 3x1

-Transamin 3x1

Pronalgess sup 2x2

-Vit K 3x1
-Vit C 3x1

Laboratorium, 3-oct-2016

-Pronalgess sup 2x2

Hb : 12,8
4

Home theraphy :

Ht : 37

-As.mefenamat Tab 500 mg 3x1

Leukocyte : 11.800

-SF 1x1

Erytrocyte : 5,1

-Cefixime Tab 200 mg 2x1

Thrombocyte : 248

-Vit C 2x1

Laboratorium, 20-oct-2016
Hb : 11,9

6-Oct-2016 Check Ca 125 : 106,6

Leukocyte : 17,800
Ht : 33
Eritrocyte : 4,7
Trombocyte : 189

CHAPTER III
THEORY
1. Definition
Endometriosis is defined as ectopic growth of endometrial gland and stroma outside
the uterus, causing infertility, pelvic pain, menstrual abnormalities and dyspareunia3.
2. Epidemiology
For endometriosis, the overall incidence (annual occurrence) and prevalence
(proportion of the population with the disease) are believed to be 5% to 10% of women of
reproductive age (between 20-35 years)1. The studies whose reports were used to derive these
figures were compromised by selection bias, the limitations of surgical diagnosis of the
disease, and the detection bias associated with retrospective studies. Clinicians need to be
aware of a number of factors that increase the likelihood of endometriosis in an individual
patient. Heritability studies indicate that the probability of endometriosis is 3 to 10 times
greater among first degree relatives of women with this disease than among control subjects 1.
Women with anomalous reproductive tracts and resultant obstruction of menstrual out flow
are also at increased risk of endometriosis. Increased parity and prolonged or irregular menses
decrease the likelihood of the disease, whereas nulliparity, subfertility, and prolonged intervals
since pregnancy are all associated with an increased risk of endometriosis 4. The highest
incidence of endometriosis is in women who under go laparoscopic assessment of infertility
or pelvic pain: endometriosis will be diagnosed in 20% to 50%. The recognition of
endometriotic lesions as having a much wider range of appearance than previously identified
has been associated with increased identification rates4.
3. Etiology

The details of the complex etiologic theories of endometriosis are beyond the scope of
this guide line; readers are referred to a recent review of this topic 5. At present there is no
consensus on the cellular origin of endometriosis. Failure of immune mechanisms to destroy
the ectopic tissue and abnormal differentiation of endometriotic tissue have been suggested as
under lying mechanisms in a stromal cell defect associated with increased estrogen and
prostaglandin production, along with resistance to progesterone2. Sampson 6 is credited with
the theory of retrograde menstruation, where by menstrual tissue refluxes through the
fallopian tubes and implants on pelvic structures. This mechanism has been consistently
observed in humans and is supported by the anatomic distribution of implants of
endometriotic tissue. This theory does not explain the observation that reflux menstruation
occurs in most women but the disease in only 5% to 10% of the female population. In the
coelomic metaplasia theory, endometriotic lesions develop when coelomic mesothelial cells of
the peritoneum undergo metaplasia. Another theory postulates the circulation and
implantation of ectopic menstrual tissue via the venous or the lymphatic system, or both.
Endometriosis cell survival and growth and associated inflammation are responsible for the
clinical symptoms of infertility and pain. Inflammation, a predominant feature of
endometriotic lesions, is characterized by overproduction of cytokines, prostaglandins, and
other inflammatory substances that mediate pain and may be associated with subfertility.
Estrogen promotes the survival and persistence of endometrial lesions, as may altered immune
and inflammatory processes. The cellular and molecular etiologic theories have significantly
improved medical and surgical approaches to the resolution of endometriosis symptoms, but
continued research, both basic and clinical, is needed to better understand and manage this
disorder.
4. Diagnostic
a. Anamnesis
The signs and symptoms of endometriosis vary greatly and may be related to other
conditions or pathological processes. A full evaluation and assessment of a patients pain
experience is required to assist with diagnosis and treatment6,7.
Pain related to endometriosis may present as any of the following.
Painful menstruation (dysmenorrhea)
Painful inter course (dyspareunia)
Painful micturition (dysuria)
Painful defecation (dyschezia)
Lower back or abdominal discomfort
7

 Chronic pelvic pain (non-cyclic abdominal and pelvic pain of at least 6 months
duration)8.
Atypical presentations suggesting more significant disease involvement include
cyclic leg pain or sciatica (nerve involvement), cyclic rectal bleeding or hematuria (bowel
or bladder invasion), and cyclic dyspnea secondary to catamenial pneumothorax.
Although endometriosis may present through the above symptoms and signs,
many women with endometriosis are asymptomatic; the lesions may be an incidental
finding at surgery. Also, the symptoms may not appear immediately after menarche but
may develop later in life. Those with pain from endometriosis often live with a condition
that is considered a chronic, progressive, and relapsing process.
For all patients with these chief complaints a detailed pain and gynaecologic
history should be taken to explore and rule out other causes of pain (Table 2.1). Focused
history taking would also include reproductive health questions. (on age at menarche,
cycle frequency and regularity, previous pregnancies, and use of oral contraception or
hormonal treat ments). Contributory medical and surgical history, as well as family
history of endometriosis or gynaecologic cancers, should be sought. Tools for evaluating
pelvic pain are available through the International Pelvic Pain Society.
b. Examination
Physical examination is essential to determine the diagnosis and appropriate care,
as well as to rule out other disorders, including acute conditions that may require
immediate atten tion. Examination should include an assessment to determine the
position, size, and mobility of the uterus: a fixed, retroverted uterus may suggest
severe adhesive disease. A rectovaginal examination may be necessary and
appropriate to palpate the uterosacral liga ments and rectovaginal septum, which may
reveal tender nodules suggestive of deeply infil trating endometriosis. Adnexal
masses discovered on physical examination may suggest ovarian endometriomas.
Examination during menses may improve the chances of detecting deeply infiltrating
nodules and the assessment of pain9.

c. Investigation
Ultrasonography is the first-line investigational tool for suspected endometriosis. It
allows detection of ovarian cysts and other pelvic disorders such as uterine fibroids.
There is little support for the routine use of blood work or other imaging studies in the
primary investiga tion of these cases. Although the serum level of cancer antigen 125
(CA-125) may be elevated in moderate to severe endometriosis, its deter mination is
not recommended as part of routine investigation. In a meta-analysis of 23 studies
investigating serum CA-125 levels in women with surgically confirmed
endometriosis, the estimated sensitivity was only 28% for a specificity of 90% 10.
However, any undiagnosed pelvic mass should be evaluated according to the SOGC
guidelines11. in which the CA-125 level is a component of the Risk of Malignancy
Index.
d. Recommendation

1. Investigation of suspected endometriosis should include history, physical, and

imaging assessments. (III-A)
2. Routine CA-125 testing as part of the diagnostic investigation of endometriosis
should not be per formed. (II-2D)
When endometriosis is thought to have a deeply invasive component (i.e.,
bowel or bladder invasion), ancillary tests such as colonoscopy, cystoscopy, rectal
ultrasonography, and MRI may be required.
The gold standard for diagnosis is direct visualization at laparoscopy and
histologic study. Disease severity is best described by the appearance and location
of the endometriotic lesions and any organ involvement. The American Society
for Reproductive Medicine has developed a classification to allow staging of
endometriosis at laparoscopy12. This type of classification has limited utility for
clinical management since disease stage may not correlate with the patients
symptoms. Most communications to health care providers will include a
classification of disease as mini mal, mild, moderate, or severe, which is
described in the ASRM classification system. It is important to appreciate that the
diagnosis and description of disease are highly subjective and will vary among
practitioners. Video and image capturing systems allow for objective
documentation of disease at laparoscopy.
Diagnostic laparoscopy is not required before treat ment in all patients
presenting with pelvic pain. Although laparoscopy is considered a minimally
invasive procedure, it still carries the risks of surgery, including bowel and
bladder perforation and vascular injury. The over all risk of any complication with
laparoscopy, minor or major, is 8.9%13.
5. Management theraphy of endometriosis
Treatment of endometriosis consists of prevention, observation, hormonal therapy,
surgery and radiation.
1. Prevention
When disminorea severe occurred in a young patient, the possibility of varying
degrees of obstruction of menstrual flow should consider the possibility of a horn of the
uterus that blunt the uterus bicornuate or a blockage septum uterus or vaginal should
remember that cervical dilation to allow expenditure menstrual blood easier on patients
10

with disminorea great14. Then, those opinions of Meigs, Meigs found pregnancy is the best
prevention for endometriosis. Symptoms of endometriosis was reduced during and after
pregnancy because of the regression of the endometrium in the nests of endometriosis.
Thus the marriage should not be delayed for too long and this will be as soon as possible to
have children that are desirable in a time not too long. Such an attitude is not only a good
prophylaxis for endometriosis, but also prevent infertility after endometrial arise, but it also
should not carry out checks coarse or scrapings during menstruation, because menstrual
blood can flow from the uterus into the fallopian tubes and the pelvic cavity15.
2. Observation
This treatment would be useful for women with symptoms and mild physical
abnormalities. In a rather old woman, this oversight can be continued until menopause,
because after that endometriosis symptoms disappear. During this observation can be given
palliative treatment in the form of providing analgesic to relieve pain15.
3. Non surgical theraphy
The first principle of this hormonal treatment is to create an environment of low
hormone estrogen and acyclic. Low estrogen causes atrophy of endometriosis tissue.
Acyclic circumstances that prevent the occurrence of menstruation, which means no
emission of normal endometrial tissue or tissue endometriosis. Thus the inevitable
emergence of a new nest for endometriosis retrograde transport loose endometrial tissue
and prevent discharge and bleeding endometriosis tissue that cause pain due to stimulation
of the peritoneum.
The second principle is to create an environment of high androgen or high
progesterone which can directly cause tissue atrophy of endometriosis15.

Medical Therapies
Gonadotropin-releasing hormone agonists (GnRH), oral contraceptives, Danazol,
aromatase inhibitors, and progestins are mainstays.

a.

Aromatase Inhibitors
- Endometriotic implants express aromatase and consequently generate estrogen,
maintaining own viability.
- Aromatase inhibitors inhibit local estrogen production in endometriotic implants
themselves as well as in ovary, brain, and adipose tissue.
11

- They significantly reduce endometriosis- associated pain when compared with GnRH
agonists alone.
b. Oral contraception
- Generally well tolerated; fewer metabolic and hormonal side effects than similar
therapies.
- Relieve dysmenorrhea through ovarian suppression and continuous progestin
administration.
- Often a simple, effective choice to manage endometriosis through avoidance or delay
of menses for upwards of 2 years.
c. Progestins
- Inhibit growth of lesions by inducing decidualization followed by atrophy of uterinetype tissue.
- Compared to GnRH therapy, both modalities show comparable effectiveness.
- Medroxyprogesterone acetate proven for pain suppression in both oral and injectable
preparations.
- Adverse effects include weight gain, fluid retention, depression, breakthrough bleeding.
- Mirena intrauterine device shown to be effective in reducing pain and may be
d.
e.
-

considered alternative to hysterectomy in adenomyosis patients.

NSAID
Proven efficacy for treatment of primary dysmenorrhea
Acceptable side effects
Reasonable cost
Ready availability
Danazol
Among oldest of medical therapies for endometriosis
Inhibits midcycle FSH and LH surges and prevents steroidogenesis in corpus luteum
Higher incidence of adverse effects v more recent therapies
Androgenic manifestations (oily skin, acne, weight gain, deepening of voice, hirsutism)

may be intolerable
f. GnRH
- Produces hypogonadotrophic-hypogonadic state through downregulation of pituitary
gland
- GnRH agonists as effective as other medical therapies in relieving pain and reducing
progression
- Efficacy limited to pain suppression; no fertility improvement
- Disadvantages include high cost of medication, bone mineral density loss, and
intolerable hypoestrogenic side effects
- Preoperative therapy reported to reduce pelvic vascularity and size of lesions, thus
reducing intraoperative blood loss
- Postoperative therapy may extend surgical relief rates
12

4.

Surgery
Their functioning endometrial tissue is an absolute requirement growth of
endometriosis. Therefore, at the time of surgery, should be able to determine whether or not
the ovaries maintained. In early endometriosis, women who want to have children should
be maintained ovarian function. In contrast to the widespread endometriosis in the pelvis,
particularly among older women. Generally on the conservative surgical treatment of
endometriosis nest removed leaving the uterus and ovaries of healthy tissue and adhesions
sedapatnya released. In conservative surgery, also necessary suspension of the uterus, and
removal of pelvic pathologic abnormalities. The results of surgery for infertile highly
dependent on the level of endometriosis, in patients with severe disease, surgery is not
recommended for infertile purposes15.
Endometriosis should only be treated when either pain or infertility is a presenting
symptom. As an incidental finding at the time of surgery, endometriosis does not require
any medical or surgical treatment. Suspected ovarian endometriomas or pelvic masses
should be evaluated according to the SOGC guide lines for pelvic masses 1. The surgical
management of endometriosis involves careful consideration of the indications for surgery,
preoperative evaluation, surgical techniques, surgeon experience, and ancillary techniques
and procedures. Indication Surgical management of endometriosis is indicated in the
following groups.
1. Patients with pelvic pain
a. who do not respond to, decline, or have contraindications to medical therapy
b. who have an acute adnexal event (adnexal torsion or ovarian cyst rupture)
c. who have severe invasive disease involving the bowel, bladder, ureters, or pelvic
nerves 2. Patients who have or are suspected to have an ovarian endometrioma
a. Patients for whom the uncertainty of the diagnosis affects management (as with
chronic pelvic pain)
b. Patients with infertility and associated factors (i.e. pain or a pelvic mass)

Laparotomy
Laparotomy is not always necessary before medical management of pelvic pain
is started. In women with severe dysmenorrhea or chronic pelvic pain that is
13

compromising their quality of life, management of the pain is required whether or not
endometriosis is the cause. Since all the management strategies for endometriosis are
relatively general strategies to decrease inflammatory conditions in the pelvis, the
treatments are applicable to pelvic pain whether a diagnosis of endometriosis is made or
not. The presence of endometriosis can be strongly suspected in cases of severe
dysmenorrhea unresponsive to NSAID treatment, with pelvic tenderness and nodularity
on palpation of the uterosacral ligaments and rectovaginal septum, or with ultra sound
documentation of an ovarian cyst with an appearance typical of an endometrioma. In
these situations, laparoscopy for diagnosis is not necessary before medical treatment.
Laparatomy should generally be performed only if the surgeon is prepared to vaporize
or excise lesions if endometriosis is discovered, since there is good evidence that
surgical management provides long-term pain relief for up to 50% of patients with
endometriosis1,3.
5. Radiation
This treatment aims to stop ovarian function, but it is not done anymore, unless there
are contraindications to surgery15.
CHAPTER IV
DISCUSSION
Endometriosis is defined as ectopic growth of endometrial gland and stroma outside the
uterus, causing infertility, pelvic pain, menstrual abnormalities and dyspareunia.
In the following case report presented a case of a woman 24 years old that come to
obstetric and ginecology polyclinic on 18 october 2016 with a diagnosis endometriosis cysts.
Patients schedule for laparotomy surgery on date 19 october 2016. Until now, the exact cause is
unknown and suspected endometriosis cysts is a multifactorial disease. Predisposing factors in
these patient is likely due to the age of patient 24 years where the tumor is most often provide
clinical symtoms reproductive age (between 20-35 years). The problems on this case were :
1. Was diagnosis on this patient correct?
2. Was the decision to perform laparotomy is correct?
Diagnosis of endometriosis cysts upheld by symtoms, physical examination, and
investigations. The main symtomps in these patient is the pain that felt since almost 1 years in
lower abdomen in the area of the pubic symphysis. Then the lump increasingly enlarged and
palpable mass solid not have pain the size of the mass like babys head.The pain appear when
14

menstruation period and also be affected by activity. Beside that, she have a irregular
menstruation period every 36 days and disminorrhea (-), metorhaggia (-), menarche : 13 years
old. LMP : 24 / 09/ 2016. Other complainments like fever (-), nausea (-), vormittus (-).
Physical examination of these patient were found vital status in good condition, which
means that patients hemodynamic still good. General physic examination found that conjungtiva
wasn,t anemic. On inspection found slightly enlarge mass in lower abdomen above the pubic.
Abdominal palpation, palpable mass solid not have pain the size of the mass like babys head.
Investigation by ultrasound in these patient, it was shown uterus size of normal and 2
mass with size I : 10 x 9 x 9 cm dan II : 10 x 9 x 9 cm, with the impression endometriosis cysts.
It can be deducted that the patients diagnosis is endometriosis cysts through the results of
anamnesis, physical examination, and investigations were carried out. In the anamnesis that
support the diagnosis of endometriosis cysts was obtained complaints of pelvic pain. Then from
the physical examination was found fundus symphisis three fingers above the pubis. From the
laboratory found that haemoglobin normal (11,9 gr/dl), hematocryte normal (33%), thrombocyte
normal (189), leucocyte increase become (17.800/ul), and Ca 125 abnormal (106,6 U/mL).
Laparoscopy should generally be performed only if the surgeon is prepared to vaporize or
excise lesions if endometriosis is discovered, since there is good evidence that surgical
management provides long-term pain relief for up to 50% of patients with endometriosis.

15

CHAPTER VI
CONCLUSION
Endometriosis is defined as ectopic growth of endometrial gland and stroma outside the uterus,
causing infertility, pelvic pain, menstrual abnormalities and dyspareunia.
For endometriosis, the overall incidence (annual occurrence) and prevalence (proportion of the
population with the disease) are believed to be 5% to 10% of women of reproductive age
(between 20-35 years).
Etiology of endometriosis cysts still unknown (idiopatic). But many risk factors for
endometriosis: nulliparity, infertility, reproductive age, hormonal, etc.
Endometriosis is a chronic, costly disease requiring long-term, multidisciplinary treatment
Profound personal and economic impact underscores urgent need for continued research and
improvement in diagnostic and treatment modalities.
Timely intervention and appropriate, multifactorial treatments may restore quality of life,
preserve or improve fertility, and lead to long-term effective management in absence of
permanent cure.

16