Presence of endometrial surface epithelium and/or endometrial glands and stroma outside the lining of the uterine cavity

Gynecology by Ten Teachers 18th Edition

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus which induces a chronic, inflammatory reaction

Green top guidelines No 24 October 2006 : The investigations and management of endometriosis

One of the commonest benign gynecological conditions Estimated 10 15 % of women presenting with gynecological symptoms have the condition Estimated prevalence
Identifying lesions at laparoscopy undertaken for pain or investigation for infertility Sometimes seen in asymptomatic patient
At time of laparoscopic sterilization

Reproductive age Uterine and genital tract outflow abnormalities Nulliparity Early menarche Delayed childbearing Family history Ethnicity
Endometriosis is most common among Asian women, with Caucasians next. It is reported least frequently in African American women

Menstrual cycle
Regular and short cycle interval, with longer duration and heavy menstrual flow

The commonest site of deposition

Less common are

Cervix Round ligament Bladder Umbilicus Appendix Laparotomy scar

Ovary Peritoneum of recto vaginal cul-de-sac of Pouch of Douglas Sigmoid colon Broad ligament Uterosacral ligament

Precise aetiology still unknown 4 theories:

1. 2. 3. 4.

Menstrual regurgitation and implantation (metastatic theory of Sampson) Coelomic epithelium transformation Genetic and immunological factors Vascular and lymphatic spread

Interaction between one or more theories endometriosis

Retrograde menstrual regurgitation of viable endometrial glands and tissue Implantation on the peritoneum surface Endometriosis

Endometriosis is commonly seen in women with genital tract abnormalities leading to vaginal outflow obstruction

Mullerian duct, peritoneal cells and cells of ovary share a common origin Theses cells undergo de-differentiation Transform into endometrial cells

Trigger : hormonal stimuli of ovarian origin, inflammatory irritation

May alter a womens susceptibility to develop endometriosis Increased incidence in first degree relatives of patient with endometriosis Racial difference high among oriental women and low in women of Afro-Carribean origin

Vascular and lymphatic embolization to distant sites (outside peritoneal cavity) e.g. foci in joints, skin, kidney and lung

Endometriosis

Free implants

Enclosed implants

Healed lesion

Free implants
Characteristics
Polypoidal cauliflower like structure Grows along the surface or cover the cystic structure Presence of a surface epithelium supported by endometrial stroma Endometrial glands may be present or absent

Cyclical changes with both secretory and menstrual bleeding Lesion highly responsive to alterations of estrogen secretion
So, it sensitive to hormonal suppressive therapy

Endoscopic image of red endometriotic lesions in the Pouch of Douglas and on the right sacrouterine ligament

High power section of peritoneum with red lesion Gland lined by endometrial like epithelium and surrounded by stroma

Enclosed implant
The implant has become covered with surface layer of peritoneum
Located within tissue or within part of growing lesion

Present as wedges shaped extensions of stroma (ramification) Often deep in local tissue planes connecting lesions with one another

Healed lesions
Characteristic
Had feature of cystically dilated glands Containing a thin glandular epithelium Supported by small numbers of stromal cells surrounded by connective tissues

Absence of functional stromal tissue Enclosure the implant by increasing amount of scar tissue
Make it insensitive to hormonal stimuli

Puckered blue-black lesion with surrounding white fibrous plaque

Powder-burn lesion

High power biopsy of lesion showing fibrotic tissue and endometrial glands which are inactive ( no active bleeding )

Histological subtypes Free

Components

Hormonal response Proliferative Secretory Menstrual changes Proliferative Variable secretory changes No menstruation No response

Laparoscopic appearance Hemorrhagic vesicle/ bleb

Surface epithelium Glands Stroma Glands Stroma

Enclosed

Papulae and later nodules

Healed

Glands only

White nodule or flattened fibrotic scar

Endometrial deposits correlation b/t histology morphology and functional activity

Present either as: superficial form

superficial haemorrhagic lesions red vesicles blue black powder burn lesions

enclosed haemorrhagic cyst

Adhesion formation

Endometrioma (endometriotic/ chocolate cyst of the ovary) cyst wall can be lined by free endometrial tissue if long standing cyst wall becomes covered by thickened fibrotic tissue

Endometrioma:
Formed from lesions commenced on the outer surface of the ovary Inversion of the ovarian cortex Increasing inflammatory reaction of site of inversion Become enclosed within the ovary Inverted ovarian cortex slowly distended and filled with chocolate fluid from repeated menstrual bleed Leakage from cyst wall leading to adhesion formation

Endoscopic image of a ruptured chocolate cyst in left ovary