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Endometriosis externa or endometriosis

- is a disease characterized by presence of tissues

morphologically, biologically and functionally similar to
normal endometrium (i.e. it contains functional end glands &
stroma) at ectopic locations other than the uterine mucosa
- is a disease of contrast because it is benign, not a
neoplastic condition but however it is locally invasive,
disseminates widely & also has malignant transformation
- Prevalence: 10% ; 30-40% in infertile women; increased
prevalence due to:

Real increase Apparent increase

Delayed marriage ed diagnostic procedures
(laparoscopy, laparotomy)
Postponement of 1st conception ed awareness about disease
complex among gynaecologists
Small family norm

- Sites of endometriosis:

Abdominal Extra-abdominal Remote

Ovary (+nce of Umbilicus Lungs
Pelvic peritoneum Abdominal scar of Pleura
caesarean section
Pouch of Douglas / Episiotomy scar Deep tissues of
Cul-de-sac / arms
rectovaginal pouch
Uterosacral Vagina Deep tissues of
ligament thighs
Broad ligament Cervix Nasal mucosa
Pelvic lymph nodes
Gut, appendix
Abdominal: Extrabdominal: Remote: rare
structures below uncommon; only in
the level of susceptible women
umbilicus; most
common site;
uncommon ones
are KUB, gut,

- Pathogenesis:

Theory Description Applicable to

Retrograde Menstruation-RM per se Pelvic
menstruation thru UTs + genetic endometriosis
(Sampson's factorsimplantation
theory) (ovaries, USL) --- +
ovarian hormones---
cyclic growth &
Coelomic Chronic irritation of Endometriosis of
metaplasia peritoneum by blood + umbilicus,
(Meyer & Ivanoff) mullerian t/s remnants abdominal
in peritoneum viscera, pelvic
-------CM------normal peritoneum, RVS
Direct Implantation & growth Endometriosis of
implantation of endometrial & abdominal scar,
decidual t/s at ectopic episiotomy scar,
sites in susceptible vagina, cervix
Lymphatic theory Normal endometrium---- Endometriosis of
(Halban) metastasize thru pelvic lymph
draining lymphatic nodes
channels of uterus---to
pelvic LNs
Vascular theory Hematogenous spread Endometriosis of
distant sites
(lungs, pleura,
arms, thighs,
nasal mucosa)
Environment Somatic mutations of Ovarian & deep
theory cells due to infiltrating
environmental endometriotic
pollutants, dioxins lesions

Genetic & Genetic Immunologi Endometriosis in

immunological factors: cal factors: 1st degree
factors <10% pts Defect in relatives; pelvic
6-7 times local endometriosis
increased cellular with subclinical
incidence immunity inflammation
in 1st growth with increased
degree Activated peritoneal fluid
relatives macrophag
Multifactor es:
ial increased
inheritanc phagocytos
e is,
motility of
secrete IL-
1, TNF-

- Pathology:
- Under the action of ovarian hormones, changes in
endometrium (glands & stroma) in ectopic sites take place
i.e proliferative changes / growth but no secretory
changes due to deficiency of steroid receptors
- periodical or cyclical growth & shedding until menopause
- periodically shed blood:
a) spill----blood---irritant---surrounding dense t/s rxn---
adhesion & fibrosis---puckering of peritoneum; dense
adhesions amongst pelvic strts but fallopian tubes
remain patent
b) encysted-----cyst has 2 fates
i) cyst----tenseruptures
ii) cyst----enlarges----shrinks in betn periods as
serum is absorbed-----cyst content is chocolate
colored----chocolate cyst----common site:
ovary------endometrial cyst/endometrioma also
called chocolate cyst due to hemmorhagic
follicular / corpus luteum cyst or due to bleeding
into cystadenoma

Gross / Naked eye Microscopic

- depends upon: - contains endometrial t/s
i) organ involved (both glands & stroma)
ii) extent of lesion with or without
iii) surrounding t/s rxn hemosiderin (blood
pigment) laden
macrophages or
pseudoxanthoma cells
adjacent to lining
- powder burn/black dot/ - cyst wall composed of
match stick spots fibrous t/s & compressed
appearance in USL, POD in outer ovarian cortex
pelvic endometriosis
- chocolate cyst of varying - cyst wall lining absent or
sizes (bluish colorations) flattened/cuboidal or with
of ovary (usually B/L); granulation t/s due to
ovary freq involved pressure effect inside cyst
- subovarian adhesions;
ovaries adherent to pelvic
strts including rectum & SC
- subtle appearances:
i) red flame shaped
ii) red polypoid areas
iii) white peritoneal
iv) circular peritoneal
v) yellow brown patches
- fibrosis & scarring in
peritoneum surrounding
implants (puckering):
typical finding

- Diagnosis:
- Clinical diagnosis

Classic symptoms Physical examination

- increasing secondary - pelvic examination
- dyspareunia - abdominal examination
- infertility - rectal or rectovaginal
- chronic pelvic pain
- abdominal pain
- menstrual abnormality
- Serum markers

CA-125 MCP-1 (Monocyte

Chemotactic protein)
- not specific as increased in - increased in peritoneal fluid
epithelial ovarian carcinoma of women with endometriosis
- seen only in severe
- helpful for F/Up cases (to
detect any recurrence after
therapy & to assess
therapeutic response)
- Imaging

Ultrasonogr CT MRI Colonoscopy,

aphy (Magnetic rectosigmoido
Resonance scopy,
Imaging) cystoscopy
not much better than diagnostic done when
helpful in US in tool respective
diagnosis of diagnosis organs are
peritoneal involved
TVS useful for
(Transvaginal deep
ultrasonograp infiltrating
hy) can detect endometriosi
ovarian s
- TVS & characteristi
endorectal c
ultrasound hyperintensit
can detect y on T1
rectosigmoid weighted
endometriosis image &
y on T2
- Gold standard for confirmation: double puncture
laparoscopy or laparotomy

Confirmation of lesion with site, size & extent: classic lesion
of pelvic endometriosis (powder burn or match stick spots on
peritoneum of PODfindings may be recorded on video/DVD
Biopsy can be taken at the same time (microscopically:
endometrial glands, stroma, hemosiderin-laden
macrophages or pseudoxanthoma cells)
Staging can be done
Extent of adhesions could be recorded
Opportunity to do laparoscopic surgery if needed
- Biopsy confirmation of the excised lesion: ideal; but ve
histology does not exclude it
- Staging or classification of endometriosis based on
i) appearance, size & depth of peritoneal implants
ii) appearance, size & depth of ovarian implants
iii) degree of cul-de-sac obliteration
iv) presence, extent & type of adnexal adhesion
- Staging of diagnosed endometriosis based on laparoscopic
i) to predict prognosis
ii) to choose therapy
iii) to evaluate T/t protocol
- Stage determined by adding specific points given to each
- American Fertility Society (AFS) scoring
- Limitations :

laparoscopy or laparotomy has to be done

interobserver & intraobserver variations
staging not correlated with fertility outcome
staging not correlated with optimum mode of therapy
no correlation with extent of disease & degree of symptoms
- Differential diagnosis
i) Chronic pelvic infection
ii) Ovarian endometrioma
iii) Rupture of chocolate cyst
- Complications
i) Endocrinopathy
ii) Infection of chocolate cyst
iii) Rupture of chocolate cyst
iv) Intestinal & ureteral obstruction