ENDOMETRIOSIS

DEFINITION
ENDOMETRIOSIS IS DEFINED AS THE PRESENCE OF ENDOMETRIAL TISSUE (GLAND AND STROMA) OUTSIDE THE UTERINE CAVITY (Oestrogen dependent disease)

INTERNAL

EXTERNAL

ADENOMYOSIS

PELVIC VISCERA PERITONEUM

LOCALIZATION OF ENDOMETRIOSIS

INTRA-PELVIC

EXTRA-PELVIC

GYNECOLOGIC SITE

NON-GYNECOLOGIC SITE

ETIOLOGY
Ectopic transplantation of endometrial tissue Coelomic metaplasia The induction theory
GENETIC IMMUNOLOGIC

FACTORS

FACTORS

Ectopic transplantation
Endometriosis is caused by the seeding or

implantation of endometrial cells by transtubal regurgitation during menstruation (Sampson hypothesis, 1920) Ovarian endometriosis may be caused by either retrograde menstruation or by lymphatic flow from the uterus to the ovary.

COELOMIC METAPLASIA
The transformation (metaplasia) of

coelomic epithelium into endometrial tissue. This theory has not been supported by either strong clinical or experimental data.

Induction theory
The Induction theory is, in principle, an

extension of the coelomic metaplasia theory. An edogenous (undefined) biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissue. This theory has been supported by experimental in Rabbits, but not in women and primates.

GENETIC FACTORS
The risk of endometriosis is seven

times greater if a first-degree relative has been affected by endometriosis. A relative risk for endometriosis of 7.2 has been found in mothers and sisters. A 75% incidence has been noted in homozygotic twins of patients with endometriosis.

Immunologic Factors
Not all women who have retrograde

menstruation develop endometriosis. Endometriosis may develop as a result of reduced immunologic clearence of viable endometrial cells from the pelvic cavity. Natural Killer (NK) cell theory. Cytokines theory (alfa-TNF). Macrophage-epidermal growth factor (EGF), macrophage-derived growth factor (MDGF).

10% TO 15% OF PREMENOPAUSAL WOMEN HAVE SOME FORM OF ENDOMETRIOSIS

IF UNCONTROLLED

PELVIC PAIN DYSMENORRHOEA DYSPAREUNIA INFERTILITY

CESSATION OF STEROID HORMONE SECRETION AT MENOPAUSE

Cessation of symptoms

CLINICAL SYMPTOMS

DIRECT INVASION OF PELVIC TISSUE

LOCAL IRRITATION FROM SECRETORY PRODUCTS OF ENDOMETRIAL GLANDS

SCAR TISSUE FORMATION DISTORSION OF PELVIC ORGAN

Clinical Examination
In many women with endometriosis, no

abnormality is detected during the clinical examination. Uterosacral or cul-de-sac nodularity, painful swelling of the rectovaginal septum and unilateral ovarian (cystic) enlargement. Uterus is often in fixed retroversion and the mobility of the ovaries and fallopian tubes is reduced

Histological Confirmation
Microscopic endometriosis is defined as the presence of endometrial gland and stroma, with or without hemosiderin-laden macrophage.

Laboratory test
There is no blood test available for

the diagnosis of endometriosis. Serial CA-125 determination may be useful to predict the recurrence of endometriosis after therapy.

DECREASING OF FERTILITY
* ABNORMAL LEVEL OF PERITONEAL
PROSTAGLANDINS AND MACROPHAGES * DISTURBANCES IN FOLLICULOGENESIS * DISRUPTION OF OVULATORY CORPUS LUTEUM FUNCTION

THE MORE FREQUENT USE OF LAPAROSCOPY TO INVESTIGATE PELVIC PAIN HAS REVOLUTIONISED BOTH THE DIAGNOSIS AND THERAPEUTIC ASPECS OF ENDOMETRIOSIS.

EARLY ENDOMETRIOSIS

* EXCRESCENCES * FLAME-LIKE LESSIONS * WHITE OPACIFICATIONS *ISOLATED UNEXPLAINED ADHESIONS

CLASSIFICATION
Appearance and Size Depth of peritoneal and Ovarian

implants The presence, extent, and type of adnexal adhesions The degree of cul-de-sac oblitaretion

( r-AFS )

THE IMPORTANT OF ACCURATE STAGING AND CLASIFICATION OF SEVERITY OF ENDOMETRIOSIS

PLANNING OF TREATMENT

COMPARISON OF DIFFERENT TREATMENTS

TREATMENT OPTIONS

OBSERVATION

MEDICAL

SURGERY
LAPAROTOMY LAPAROSCOPY

NO TREATMENT

OESTROGEN & PROGESTAGEN PROGESTAGENS DANAZOL GnRH AGONIST

The aim of treatment

Is to limit progression of the disease so it is advisable to warn patients

that therapy to this end may not resolve symptom

(Kevin Forbes, 1989)

PROGESTAGENS
INHIBITS GONADOTROPHIC FUNCTION

HYPOESTROGENICITY + PSEUDOPREGNANCY

ENDOMETRIAL ATROPHY

SIDE EFFECTS
HIGH DENSITY LIPOPROTEIN INFERTILITY

Progestogens
Medroxy progesterone acetate Megestrol acetate Lynestrenol Dydrogesterone

EFFECTIVITY OF PROGESTAGEN :

Oral administration in mild and moderate cases

of endometriosis over 90 day period have been shown to have subjective and objective

improvement at repeat laparoscopy.

Petrucco,1989

COMBINED ESTROGEN-PROGESTOGEN ORAL CONTRACEPTION

PSEUDOPREGNANCY-STATE

SIDE EFFECTS
BREAKTHROUGH BLEEDING NUSEA, BREAST TENDERNESS WEIGHT GAIN AND DEPRESSION

Antiprogestins
Gestrinone Danazol

DANAZOL
is a derivative of ethisterone with androgenic properties Reduction of LH and FSH level Reducing of estradiol level Supressing ovulation Inhibiting endometrial growth

SIDE EFFECTS Weight gain, muscle cramps Acne, nausea, water retention Hot flashes, dry vaginal and Deppresion.

GnRH-Agonist
Suppresion of Gonadotrophin secretion Reduction of FSH and LH Complete ovarian suppression complete endometrial atrophy

Gonadrotropin-RH
Leuprolide Goserelin

Buserelin
Nafarelin Tryptorelin Tapros

Outcomes of the GnRHa treatment

When second-look pelviscopies (laparoscopies) were performed at the end of the treatment phase, a reduction in the amount and size of the implants was observed. Schweppe,1996

The routes of GnRHa administration

Intranasal

Subcutaneous injections
Depot injections Implant

Treatment options for endometriosis

Endometriosis
Symptom Reproductive status Completed family Reproductive potential Mild Severe Combined Combined Medical Dyspareunia

Total abdominal hysterectomy Combined

Treatment options for endometriosis

Endometriosis
Symptom Reproductive status Completed family Reproductive potenttial Mild Severe

Dysmenorrhoea

Total abdominal hysterectomy with conservation ovary Medical Combined

Prostaglandin synthetase inhibitors

Treatment options for endometriosis

Endometriosis
Symptom Reproductive status Completed family Mild Medical Pelvic pain Severe Combined

Counseling
Total abdominal hysterectomy and salphingooophorectomy

Reproductive potential

Medical

Combined

Counseling

Treatment options for endometriosis

Endometriosis
Symptom Reproductive status Mild Medical Combined Infertility Aggressive treatment of associated factors after therapy specifically for endometriosis Severe Combined

Summary
The procedure of laparoscopic exploration in

women pelvic pain is important to verify early endometriosis. The basis of all medical therapy is to control endometriosis by supression of ovarian function. The treatment options for endometriosis should be determined by : age, symptoms, reproductive status and severity of condition.

Thank You