CASE REPORT

ENDOMETRIOSIS
Written By :
Muhammad Fadhil
CONSELOUR : dr. Ni Made Indri, Sp.OG

Definition
Endometriosis is a disease in which endometrial

glands and stroma implant and grow in areas

outside the uterus
Most commonly implants are found in the pelvis
Lesions may occur at distant sites: pleural

cavity, liver, kidney, gluteal muscles, bladder, etc

Epidemiology of Endometriosis
This disease affects 5% to 10% of women of

reproductive age
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%

Etiologies of Endometriosis
Sampson's theory: Retrograde menses

and peritoneal implantation

Most women retrograde menstruate

Meyer's theory: Coelomic metaplasia

Low incidence of pleural disease

Halban's theory: Hematogenous or

lymphatic spread to distant tissues

Does not explain gravity dependent disease sites

Immunogenic defect

Clinical Presentation
Pelvic pain
Infertility
Pelvic mass

Pelvic Pain
Frequency
Cyclic: Variable length prior to and after

menses
Acyclic: constant and unrelenting

Associated activities
May include dyspareunia, dysuria

Other sites of pain

Muscle regions
Distant tissues

Infertility
Moderate to severe disease
Adhesions
Distortion of normal anatomy
Prevent sperm-egg interaction

Minimal to mild disease

Mild infertility
Mechanism unknown

Physical Findings
Tender nodules along the uterosacral

ligaments or in the cul-de-sac, especially

just before menses
Pain or induration without nodules

commonly in the cul-de-sac or rectovaginal

septum
Uterine or adnexal fixation, or an adnexal

mass

Diagnosis of Endometriosis
Direct visualization of implants
Laparoscopically or Laparotomy
Conscious pain mapping
Imaging of endometriomas
MRI appears to be best (3 mm implants)
Ultrasound helpful in office setting
Biochemical markers
Lack specificity

Treatment of Endometriosis
Management of pain
Surgery
Medical therapy
Treatment of infertility
Surgery
Ovulation induction
Assisted reproductive technology

Management of Pain
Surgical treatment
Ablation of endometrial implants
Lysis of adhesions
Ablation of uterosacral nerves
Resection of endometriomas

Combined surgical and medical treatment

Treatment of Pain
Medical management

(ovarian suppression, removal of

estrogen)
Oral contraceptives, progestin, danazol
GnRH agonist
Aromatase inhibitors

Treatment of Infertility
Removal of disease
Surgery improve conception rates at all stages
Ovulation induction
Gonadotropins with ovarian suppression
Insemination with either clomiphene or FSH
Medical suppression of ovarian function
No benefit
Assisted reproductive technology

Case Report
Personal Data
Name : Miss.R
Age

: 24 years old
Sex : Female
Marital Status : Single
Address : Indonusa Housing Block F No.5
Profession : Student
Religion : Islam
Ethnic : Minang
Education: Senior High School
Date of Admission : 18-10-2016
Medical Record Number : 162041

Anamnesis
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
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 : Tympanic
Au : 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

Cont
Diagnosis pre op : Ovarium cysts with differensial diagnosis

Endometriosis cysts
Planning : -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

Cont

Discussion
Was the diagnosis in this case correct?? Yes
- Age of patient is 24 years old, which still relatively
productive age
Showed the right symtoms, like :
- Pelvic pain
- Irreguler menstruation

Cont
Case

Physical examination found :

- Abdomen : inspection, slightly
enlarge
Palpation, A smooth solid mass
(+),palpable lump in the area of
the pubic symphysis
USG :-Uterine size normal
- Look mass with size I : 10 x
9 x 9 cm dan II : 10 x 9 x 9

Theory

Pelvic examination
findings of :
- An enlarged, irregulary
menstruation
Imaging can be find :
- Look mass with size I : 10
x 9 x 9 cm dan II : 10 x 9 x 9

Cont
Case

Theory

From the theory that

Advise : preparation

Laparotomy on 19 oct
2016

treament of
endometriosis cysts
based on symtopatolgy,
surgerically or
combination of both