Ministry of Public Heals Service of Ukraine

«Ukrainian Medical Stomatological Academy»

«APPROVING»

on the sitting of chair of obstetrics and

gynecology №1 of UMSA

(protocol №1 from 28. 08. 2019)

Acting manager of chair of obstetric

and gynecology №1

professor ____________A.M. Gromova

METHODICAL POINTING

for the teacher of higher medical educational establishment in relation of

educational process

Educational

subject

Obstetric

Modul № 1

Subject of

lesson

Endometriosis

Course IV

faculty medical

Poltava – 2019

Endometriosis

Amount of hours: 4 hours in practical classes

The topic includes etiology and pathogenesis. Classification. Diagnosis.

Symptoms. Modern methods of treatment. Medical rehabilitation of women with

endometriosis.

Gynecological diseases of children and teens. Peculiarities of symptomatic,

diagnostics and treatment of the most widespread types of gynecological pathology of

youg girls and teens. Hyperanteflexion, retrodeviation of the uterus. Treatment,

prophylaxes. Development defects of the reproductive organs. Infantilism, impaired

sexual development, gonadal dysgenesis.

Endometriosis – benign hormone-dependent disease, which is based on

heterotopias of endometrium (glandular and stromal components), the signs of which

are nonspecific inflammation and elevated levels of enzymes on the background of

disturbances of hypothalamic-pituitary-ovarian system, immune balance in the

presence of genetic predispositions. The problem of endometriosis is medical and

social - a common cause of disruptions of working capacity and reproductive function

of women, therapeutic and diagnostic - the complexity of early clinical diagnosis and

conservative treatment in the later stages of the disease, cancer - an increasing

number of observations of malignant diseases at an early stage have been diagnosed

as endometriosis, The occurrence in general population - 5 - 10%, it occupies the

third place in the structure of gynecological diseases after inflammation and uterine

fibroids and affects, according to WHO, 25 - 30% of women of reproductive age.

27% of women who gave birth , 30 - 40% woman with infertility, 10% of girls at the

age of menarcheand approximately 2 - 5% of women in menopause are diagnosed

with endometriosis.

The hypothesis of origin according to P. J. Q. van der Linden, 1997 are: in situ

formation, transplantation, the combination of the formation of transplantation and

implantation of endometrium, embriological hypothesis, hypothesis of metaplasia due

to inflammation or hormonal stimulation, immunological theory. The risk factors

include: history of abnormal births, gynecological operations, abortions, hormonal

disorders, the decline of immunological tolerance, hereditary predisposition, early

menarche, age older than 35-45 years, reducing the length of the menstrual cycle, the

increase of menstrual blood loss, inflammatory diseases of the genitalia, the first labor

families in the older age, waiver of breast feeding, the abuse of alcohol, caffeine,

adiposity. Factors that lower the risk are: use of

hormonal contraceptives, previous use of IUD, smoking, belonging to a

particular race.

Topical classification

І. Genital endometriosis

Internal endometriosis (adenomiosis)

o Endometriosis of corpus uteri

І,ІІ,ІІІ stages depth of invasion into

endometrium : glandular, cystic, fibrous (focal, nodular, diffuse) form

o Endomeetriosis of the cervical canal

o Endometriosis of the isthmic part of the fallopian tubes

External

endometriosis

o Peritoneal

endometriosis

of ovaries (infiltrative and tumor forms)

of fallopian tubes

of pelvic peritoneum (red, black, white form)

o Extraperitoneal endometriosis

vaginal part of cervix

of vagina, vulva

retrocervical

of uterine ligaments

Parametrial, paravezical, paravaginal tissue with or

without invasion into the bladder, rectum

External-internal endometriosis

Combinations of endometriosis (genital or extragenital pathology)

Extragenital endometriosis (gastrointestinal tract, urinary organs,

skin, navel, postoperative wounds, lungs, pleura, etc.

Symptoms include: pain (pelvic pain, algodismenorrhea, dyspareunia),

infertility, hemorrhagic syndrome, long ineffective treatment of chronic genital

inflammation, mental disorders, impaired function of adjacent organs, absence of

symptoms. Typical symptoms include: dysmenorrheal, dyspareunia (sexual

disorders), infertility, pelvic pain. Less typical symptom - dysheziya (disturbance of

bowel movements), dark bloody discharges before and after menses, dysfunctional

uterine bleeding, dysuria. More rare symptoms are frequent urge to urination,

haematuria, bleeding from the rectum. Very rare symptoms are haemoptyzys (bloody

cough), intestinal obstruction, edema of the kidney and ureter, skin nodes.

Chronic pelvic pain. This is the most common symptom of endometriosis. The

intensity depends on localization of ectopy (especially pronounced in endometriosis

of isthmus, sacro-uterine ligaments, nodular form), the extent of the process, duration

of disease, individual characteristics. Menstrual cycle disturbances include

progressive algomenorrhea, menometrorragia, bloody discharges before and after

menstruation, contact bloody discharges, irregular menstruation. The disease for a

long time may be hiding under the mask of various pathological processes.

Special methods of diagnosis include: X-ray examination, ultrasound,

endoscopic methods including hysteroscopy and oth., CT, MRI ( fiber – accuracy

of diagnostics - 98-100%), cytological, histological (diagnostic accuracy 98-

100%), determination of the levels of tumor markers (CA-125, HE - 4) .

Hysterosalpingography The accuracy of diagnosis ranges from 33.2 to 97.4%.

Its not posssible to diagnose a focal or nodal form. The procedure is done 2-3 days

after menstruation or 24 hours after thorough curettage of the uterus, or 6- 8 days

after endometrial curettage because of the best penetration of contrast in endometrioid

moves. During the procedure aqueous solutions are preferred.

Ultrasound is the best and affordable screening method. There may be

difficulties in accurate diagnosis if adhesive processes are present, it is impossible to

identify depth of the lesion of external genital and extragenital endometriosis In some

of the cases the evaluation and visualization is not accurate.

Hysteroscopy. This method if Miniinvasive and highly informative. During the

procedure there is a high incidence of diagnosing submucous nodes, adenomyosis,

chronic endometritis, hyperplasia of endometrium, polyps. The procedure is done not

only for diagnosis but as a surgical method of treatment too. There is a possibility to

do biopsy or curettage, remove tumors or septas, separate adhesions.

Laparoscopy has a high diagnostic accuracy with direct visualization, ability to

biopsy and histological examination. If it is already diagnosed appropriate therapeutic

rather than diagnostic laparoscopy is applied.

Endometriosis of vagina and perineum The symptoms are: pain in the vagina

and in the pelvis from mild to severe, cyclic pain that is related to the MC, the pain

may be accompanied by local itching. The diagnosis criteria are: during menses

painful nodes may be palpated in the vagina, after the menstruation they decrease in

size or disappear leaving scars, hystological investigation may be performed.

Endometriosis of the cervix During the speculum examination cyanotic cysts

may be seen. To confirm the diagnosis colposcopy and biopsy is performed. The

sysmptoms include dark bloody discharges from vagina before and after menses. This

is the only form that the pain symptom is not present.

Endometriosis of the ovaries Emndometrial cysts of the ovaries as the small

heterotopias may be either unilateral or bilateral with different diameters of the cysts

(from 0.5 up to 10.0 cm in diameter). The symptoms include: pain especially before

and during menses, infertility, disuria, dysheziya. In case of rupture of the cysts the

pain is accompanied by vomiting, unconsciousness, elevated body temperature.

Diagnoses. Bimanual examination: One or both sides tumors are palpated in the

pelvis, inactive painful especially during menstruation, with bumpy surface, located at

the sides or behind the uterus, with a dense capsule, limited mobility, often along with

the uterus are palpated as one conglomerate. The other diagnostic measures include

ultrasound, endoscopic methods (laparoscopy)( small size cyanotic nodes or cysts of

various size).

Retrocervical endometriosis occurs relatively frequently. Behind the cervix a

dense bumpy, sharp pain, formation of different size, limited in mobility is palpated.

The symptoms are - severe pain syndrome, difficulties of bowel movement.

Extragenital endometriosis - endometriosis of the naval, endometriosis of the

postoperative scar and others.

Adenomyosis.

Pathological classification V.I.Zheleznov , AN Strizhakova

I degree. – germination of mucosa to a depth of one field of view

at low magnification of the microscope

II degree - Germination mucosa to the middle of the wall thickness

III degree - the entire muscle layer is involved into the

pathological process Symptoms. It is believed that the clinical

manifestations occur in women

with II and III degree and nodular form, whereas I degree is a histological

finding during hysterectomy . The course may be asymptomatic - 19-40%,

algomenorrhea - 76%, hypermenorrhea - 50-66%, "chocolate“ like vaginal discharges

- 56%, increased dysmenorrhea - 30% (at a depth of myometrial lesions by more than

80%) , pelvic pain, metrorrhagia, dyspareunia, infertility.

Diagnoses.. Bimanual examination (a moderate increase in uterine

anteroposterior size, tenderness, when nodular form dense nodes are palpated,

painfulness and the value of which increase during menstruation), Ultrasound

(increased anterio-posterior uterine size (80%), a thickening of one of the walls of

uterus (81.8%), the presence of zone of increased echogenicity, occupying more than

half the thickness of the myometrium (96%), hysteroscopy, hysterosalpingography,

laparoscopy.

Treatment The choice of treatment strategy depends on the age of woman,

localization and extent of the disease, severity of symptoms and duration of illness,

fertility and the need to restore fertility, the effectiveness of previous treatment,

presence of comorbidity, common therapeutic approaches. The methods of treatment

include surgical therapy, hormonal therapy, during menopause if minimal

manifestations of the disease are present expectant management, auxilary (for all

symptoms) therapy, IVF if infertility

Conservative therapy includes hormonal therapy, non-specific anti-

inflammatory therapy, medications that affect the central nervous system,

immunomodulators, antioxidants, vitamin, medications that support the function of

gastrointestinal and hepatobiliary systems, physiotherapy treatment, treatment of

comorbidity.

According to the consensus for the treatment of chronic pelvic pain syndrome

and endometriosis (2002) the first line of treatment include Monophasic COC +

nonsteroidal anti-inflammatory therapy if treatment failure. The second line of

treatment is surgery (laparoscopic or laparotomy) treatment. In our country the

second-line treatment should be considered a destination of agonist of

gonadotropin-releasing hormone after failure are surgical treatment is

performed. If untreated, the disease progresses with the development of common

tumor forms, malignant degeneration.

Indications for surgical treatment of endometriosis are

internal endometriosis combined with hyperplastic

processes of ovaries and / or endometrial precancerous

adenomyosis (diffuse or nodular form) accompanied by

hyperplasia of endometrium

Endometrial ovarian cysts (larger than 5 cm)

No effect of conservative treatment, which was carried out

continuously for 6 months

pathological involvement of other organs and systems with

violation of their functions

purulent lesions of the uterus, affected by endometriosis

endometriosis of navel

adhesions of the fallopian tube in ampullar departments with

infertility

endometriosis of the postoperative scar

presence of somatic pathology, which precludes

long-term hormone therapy

With the ineffectiveness of hormone therapy, infertility, malignant forms of

internal endometriosis, suspected malignancy In reproductive age – organ retaining

surgery by laparotomy or laparoscopy access, conservative treatment, treatment of

infertility, in perimenopause – radical surgery.

Endometriosis is a diseases characterized by the presence of a tissue similar to

endometrium in areas other than the lining of the uterus. Unlike endometrium the

endometrioid tissue is less liable to cyclic changes, less reacts to gestagens, does not

undergo secretory transformation.

The disease ranks third in the structure of gynecological disorders and affects

15–50 % of women at the childbearing age; 30–40 % endometriosis patients are

sterile. The importance of timely diagnostics and correct treatment of endometriosis

is explained by a characteristic property of the disease activity – gradual progress of

the severity of the pathological process, which leads to menstrual dysfunction,

bleeding, anemia, and development of persistent pain syndrome.

Etiology and Pathogenesis

Endometriosis is an estrogen-dependent disease. The origin of endometriosis

foci and the reasons for its dissemination have not been completely studied yet. There

are a couple of theories of endometriosis pathogenesis.

І. The transport theory is based on lymphogenous, hematogenous, and

iatrogenic (at surgical interventions, hysteroscopy, hysterosalpingography)

dissemination.

ІІ. The implantation theory is a theory of retrograde menstruation, which

explains the retrograde ingress of endometrium cells into the abdominal cavity. The

reasons for pathological implantation:

- hypoluteinism (progesterone synthesis reduction); normally in the

peritoneal fluid there is a high (higher than in blood) sex steroid concentration, which

inactivates endometrioid cells;

- protracted menstruation, cervical canal constriction, and a wide

uterotubal lumen lead to an increase in the amount of retrograde menstrual blood;

- immune dyscrasia;

- burdened heredity.

ІІІ. The theory of celomic metaplasia (degeneration) of the peritoneal

mesothelium in response to the irritant action of the endometrial tissue.

ІV. The embryonal theory explains the dysembrioplastic genesis of

endometriosis from the remains of the Mullerian ducts and primordial kidney.

Some authors regard endometriosis as an autoimmune disease, in which

immune protection disturbance leads to an increase of macrophage content in the

peritoneal fluid, activation of acid phosphatase and neutral protease. In women with

endometriosis in the peritoneal fluid there is observed disbalance of the cells

providing peritoneum resistance. Thus, there lowers the level of natural killers and

rises the content of IL-1, IL-6, IL-8. The factor, which significantly promotes

endometrium cell retention, is mesothelium integrity damage, since intact peritoneum

is a barrier for invasion.

The hormonal factor, as a reason for sterility in endometriosis, undoubtedly

plays one of the leading roles, however, the literature data on sex hormone secretion

are ambiguous and mainly testify to their increase except for progesterone, whose

content reduces.

It has been found that hormones do not influence the cells of the hormone-

dependent organs directly, but mediately by means of growth factors, gene

expression, specific proteins, and apoptosis. The balance of molecular-genetic indices

of the proliferation and apoptosis processes in the endometriosis foci is disturbed.

The study of apoptosis processes in endometriosis is a new tendency in the treatment

of this pathology.

Classification

1. Internal (70–90 %) – of the uterine body, isthmus, and the interstitial

parts of the uterine tubes. If the uterine walls thicken, internal endometriosis is called

adenomyosis.

2. External (10–30 %):

- peritoneal (of the ovaries, uterine tubes, small pelvis peritoneum);

- extraperitoneal (of the uterine neck, vagina, external genitals, retrocervical).

The most widespread external endometriosis classification was worked out by

А. Асоstа and co-authors (1973). According to this classification, there are

differentiated such stages of external endometriosis.

Minor forms:

- isolated heterotopies on the pelvic peritoneum;

- isolated heterotopies on the ovaries without adhesions and scars.

Moderate endometriosis:

- heterotopies on the surface of one or both ovaries with small cyst

formation;

- latent periovarial or peritubal adhesion abscess;

- heterotopies located on the peritoneum of the extrauterine space with

scarring process and uterus displacement without the large intestine being affected by

the pathological process.

Severe form of external endometriosis:

- endometriosis of one or both ovaries with formation of cysts larger than

2 cm;

- ovary affection with evident periovarial and/or peritubal scarring

process;

- uterine tube affection with deformation, scarring, blockade;

- peritoneum affection with extrauterine space obliteration;

- affection of the sacrouterine ligaments and peritoneum of the

extrauterine space;

- affection of the urinary tracts and/or bowels.

Many countries of the world use the classification of the American Society for

Reproductive Medicine (Table 1); this classification takes into account the extent to

which affection has spread, affection depth, and severity degree at different

endometriosis localization, for this purpose the numerical score of the indicated

parameters is formed. There are singled out four stages of the disease: I – 1–5 points,

II – 6–15 points, III – up to 16–40 points, IV – 40 points and more.

Table 1

Endometriosis Classification

(American Society for Reproductive Medicine)

Endometriosis < 1 > 3

1

cm

–3

cm

cm

Peritoneum superficial 1 2 4

deep 2 4 6

Ovaries ri

ght

superficial 1 2 4

deep 4 1

6

20

le

ft

superficial 1 2 4

deep 4 1

6

20

Extrauterine

space obliteration

p

artial

–40 c

ompl

ete

–

40

Adhesions c

over

< 1/3

c

over

<

1/3–

2/3

cover

> 2/3

Ovaries ri

ght

soft 1 2 4

dense 4 8 16

le

ft

soft 1 2 4

dense 4 8 16

Uterine tubes ri

ght

soft 1 2 4

dense 4 8 16

le

ft

soft 1 2 4

dense 4 8 16

Note: A completely soldered fibrial part of the tube scores 16 points.

According to the pathological process localization there are singled out:

І. Genital endometriosis.

1. Internal endometriosis.

1.1. Endometriosis of the uterine body of the I, II, III

(adenomyosis) stages depending on the depth of myometrium affection:

glandular, cystic, fibrous forms (focal, nodal, and diffuse forms).

1.2. Endometriosis of the cervical canal.

1.3. Endometriosis of the intramural part of the uterine tubes.

2. External endometriosis.

2.1. Peritoneal endometriosis:

- endometriosis of the ovaries (infiltrative and tumor forms);

- endometriosis of the uterine tubes;

- endometriosis of the pelvic peritoneum (red, black, and

white forms).

2.2. Extraperitoneal endometriosis:

- endometriosis of the vaginal part of the uterine neck;

- endometriosis of the vagina, vulva;

- retrocervical endometriosis;

- endometriosis of the uterine ligaments;

- endometriosis of the parametral, paravesical, and

paracolpal fat with and without invasion to the urinary bladder,

rectum.

3. Externointernal endometriosis.

4. Combined forms of genital endometriosis (genital endometriosis in

combination with some other genital or extragenital pathology).

II. Extragenital endometriosis (endometriosis of the gastrointestinal tract,

urinary organs, skin, navel, postoperative wounds, lungs, pleura, etc.).

Clinical Presentation

Genital endometriosis (GE) is characterized by a diversity of the clinical

course: from asymptomatic to the presentation of acute abdomen. The most

frequently observed clinical sign of endometriosis is pain syndrome connected with

menstrual cycle – it appears before and increases during menstruation.

Symptom polymorphism is conditioned by different localization of GE foci,

the extent to which they have spread, genital organ dysfunction, and concomitant

pathologies.

Pains are usually considerable in GE, their intensity increases as the disease is

progressing. The patients note weakness, rapid fatigability, significant loss of

exercise performance, which leads to feeling anxiety and fear.

In endometriosis pains are bilateral, their intensity does not correspond to the

process severity. Even a large endometrioid ovarian cyst may produce no pain

symptomatology, and sometimes it causes pains, especially on the eve of and during

menstruation, which may be accompanied by nausea, vomiting, loss of

consciousness. At microperforation of endometrioid cysts there not infrequently arise

peritonitis phenomena. Most uterine GE patients have profuse protracted

menstruations, metrorrhagia, sensation of heaviness, spreading in the lower abdomen.

The character of menstrual dysfunction depends largely on the localization of

endometriosis foci, the degree of affection of the genitals and pelvic organs.

Concerning some endometriosis varieties, which are characterized by serious

derangements of anatomical organizations in the region of uterine appendages, it has

been proved that fertility becomes a direct consequence of such injuries as salpingian

occlusion, adhesion deformation of the fimbriae, total isolation of the ovaries with

periovarial adhesions, direct injury of the ovarian tissue with endometrioid cysts, etc.

However, in many cases endometriosis and sterility may develop parallel for

one or a couple of common reasons. Concomitant diseases are of big importance in

this case. Different factors of sterility in endometriosis may be divided into a couple

of groups: 1) mechanical; 2) peritoneal; 3) immunological; 4) endocrine disorders.

Disorders of the general condition of the organism lead to a considerable

decrease of women’s exercise performance. In order to improve the quality of the

diagnostics of such disorders and rational choice of the treatment method there was

offered a method of assessing the degree of severity of disorders of the general

condition of the organism and exercise performance of the woman (numerical

system) in endometriosis (Table 2).

Table 2

Pain Intensity Assessment

(according to C.M. Mac Laverty, R.W. Shaw, 1995)

Pain Cause Intensity Score, points

Pain in the pelvic

region not connected with

coitus or menstruation

No.

Weak, sometimes

sensation of discomfort or

pain before menstruation.

Moderate, evident

discomfort during the most

part of the cycle.

Severe during the

whole menstrual cycle, the

patients must take

analgesics.

0

1

2

3

Dysmenorrhea No.

Weak, with some

disorders of working

capacity.

Moderate, makes the

patients stay in bed for a

couple of hours a day,

sometimes – loss of

working capacity.

Severe, makes the

patients stay in bed during

the whole day or a couple

0

1

2

3

of days.

Dyspareunia No.

Weak, tolerable.

Moderate, so

intensive that makes the

patients interrupt coitus.

So severe that makes

the patients avoid coitus.

0

1

2

3

Diagnostics

Despite the fact that modern highly informative diagnostic methods of are

being introduced, GE verification still presents difficulties.

The most typical signs and manifestations of GE are:

- syndrome of pelvic pains, which worsen during menstruations;

- sterility;

- dysfunction of the genital organs (hemorrhagic syndrome, premenstrual

spotting, hyperpolymenorrhea, metrorrhagia);

- continuous ineffective treatment of chronic inflammatory processes of the

genitals;

- psychoneurological disorders;

- dysfunction of the adjacent organs (dysuria, dyschezia).

Only complex examination of the patient in consideration of anamnesis data,

clinical manifestations, and standard methods (objective examination and results of

special methods of investigation) enable the doctor to establish the localization form

and the degree of endometriosis prevalence, and correspondingly, to administer and

successfully provide pathogenetically conditioned treatment.

Of big importance is the general examination of the genitals and examination

by means of specula, which allow finding endometrioid heterotopies. Bimanual,

vaginal-abdominal, and rectovaginal types of examination are auxiliary diagnostic

methods. Palpation of the uterus shows its form, dimensions, mobility, and

painfulness. One should pay attention to the condition of the uterine isthmus

(induration, dilation, painfulness) and posterior fornix of the vagina (infiltration, scar

changes). Examination of the uterine appendages detects their size, mobility,

painfulness, and consistency. One assesses the state of the sacrouterine ligaments

(thickening, tension, painfulness).

In order to fiagnose GE one uses the following instrument investigation

methods: 1) roentgenological; 2) urological (cystoscopy, chromocystoscopy,

radionuclide diagnostics); 3) US (transabdominally and transvaginally); 4)

endoscopic (colposcopy, proctosigmoidoscopy, laparoscopy); 5) nuclear magnetic

resonance (NMR) tomography; 6) cytological investigation method; 7) histological

study of the material taken by means of biopsy.

In order to diagnose GE, the degree and character of vascular disorders one

resorts to dopplerometric investigations of blood flow in the arteries of the organs of

the small pelvis. Among roentgenological techniques of GE diagnostic there is used

hysterosalpingography and bicontrast gynecography performedon the 2nd

–3rd

day

after menstruation or after diagnostic curettage. In this case preference is given to the

use of water solutions of radiographic contrast media.

The most typical roentgen sign in internal endometriosis is the presence of

edge shadows of different length. Their form depends on the localization of the

endometrioid foci.

Hysteroscopy shows endometrioid eyes in the form of dark red pin holes

against the background of pink-pale hue of the uterine cavity mucosa; at multiple

localization of endometriosis foci the endoscopic picture reminds the honeycomb

structure. The nodular form of adenomyosis is characterized by enlargement and

deformation of the uterine cavity due to bulging of its affected walls, on which there

are localized pathological formations with a yellow or yellow-pale hue without clear

limits, sometimes with the presence of superficial endometrioid “pupils”

Laparoscopy is the most accurate and basic diagnostic technique under modern

conditions. The diagnosis must be necessarily confirmed histologically after a biopsy

of endometrioid areas taken during laparoscopy. Laparoscopy is a first choice

procedure, because it enables examining the whole abdominal cavity from the pouch

of Douglas to the diaphragm. Endometriosis manifestations may be easily found by

their typical appearance – of the so-called “gunpowder burns”, stellar-scarry injuries

surrounded by red-blue implants on the ovaries and on the peritoneal surface of the

uterus, urinary bladder, or small intestine. The condition is characterized by

“chocolate”, bluish uni- or bilateral cysts of the ovaries, adhesive process in the small

pelvis; adhesions between immobile fixed organs and structures – under ovarian

fusions – between the ovary and the posterior folium of the broad ligament, posterior

wall of the vagina, immobile part of the sigmoid colon. The utypical signs are:

petechial peritoneum, “fiery spots”, hypervascular zones, white non-transparent

plates surrounded by scar tissue, glandular structures on the peritoneum.

The degree of the spread of external genital endometriosis is assessed in points

(see Table 1).

Microscopical endometriosis foci are the foci found by histological study of the

peritoneum, which looks unaltered. Discovery of microscopical endometriosis foci

plays an important role in the understanding of the disease pathogenesis and its

relapses after treatment.

The technique of NMR tomography in Т2-image allows detecting diffuse

formations without clear contours independent of the morphological structure of

endometrioid heterotopies. If the gastrointestinal tract may be involved in the

pathological process, and for the prophylaxis, it is expedient to conduct

fibrogastroscopy, irrigoscopy, and rectoromanoscopy.

The biochemical markers of endometriosis are not known at the moment.

According to statistics, the level of СА-125 – the substance, which is synthesized by

celomic epithelium derivatives and is an ovarian cancer marker – rises in medium-

severe and severe endometriosis and remains normal in minimal and minor process.

If endometriosis is suspected, one is recommended to detect the oncomarker twice:

during menstruation and in the follicular phase of the menstrual cycle. If the ratio of

the indices of СА-125 levels during menstruation to the index during the follicular

phase exceeds 1.5, endometriosis is possible. Reduction of the СА-125 level may

testify to treatment efficiency, and its further lowering – to a relapse.

Treatment

The therapeutic approaches, which are applied today to treat endometriosis,

include: observation, palliative, hormonal, surgical, and combination therapy.

Taking into account that endometriosis is a disease of the whole organism, and

not of a single organ, the therapy must be complex and include:

1) hormonal treatment (Table 4);

2) immunocorrectors;

3) prostaglandin inhibitors;

4) antioxidants (a combination of

vitamins А, Е, С, Р), a complex of vitamins-antioxidants (selmevit,

complevit);

5) physical therapy .

Presently, there is a certain consensus in the treatment of GE in both sterile

patients and women without reproductive intentions.

Consensus statement for the management of chronic pelvic pains and

endometriosis (Gambone J., Mittman B. et al., Fertil. Steril., 2002):

- the first-line treatment: monophase COCs + nonsteroid anti-inflammatory

therapy;

if the treatment is ineffective:

- the second-line treatment: surgical (laparoscopic or laparotomic) treatment.

Extensive clinical material allowed studying the effectiveness of such groups

of preparations as gestagens (gestrinone, norethisterone acetate, provera, linestrenol,

dydrogesterone), antigonadotropins (danazol), gonadotropin-releasing hormone

agonists (decapeptides: tritorelin, goserelin; nonapeptides: buserelin, leuprolein),

whose application ultimately brings to hypoestrogenia and, as a consequence, to the

involution of pathological implants.

Table 4

Hormonal Treatment of Endometriosis

G

roup of

prepara

-tions

Prim

ary clinical

result

Internat

ional name

Prepa

ration name

Dos

age

schedule

Contrai

ndications

1 2 3 4 5 6

C

ombined

and

estrogen

-

gestagen

preparati

ons

Anov

ulation

Ethinyl

estradiol +

testosterone or

progesterone

derivatives

Moder

n COCs

Cycl

ic schedule

–

according

to the

regimen of

COCs

dosage;

prolonged

schedule;

24+4,

42+7,

126+7

days

Thromb

oembolisms,

ischemic heart

disease;

vascular

encephalopathi

es,

considerable

lipoproteinemi

a, hormone-

dependent

tumors, severe

hepatopathies,

sicklemia

Pr

ogestins

False

pregnancy

Norethist

erone acetate

Norco

lut,

Primolut-

Nor

Fro

m the 5th

day of

menstrual

cycle 5–10

mg twice a

day during

4–6(8)

months

Hepatop

athies,

thrombosis

susceptibility,

genital tumors

Medroxy

progesterone

acetate

Prover

a, depo-

provera

5–

10 mg a

day during

6 months,

100–150

mg i.m.

once in 2

weeks

during 6

months

Tumors

of the genital

organs and

mammary

glands

Dydroge

sterone

Dupha

ston

Fro

m the 5th

day of

menstrual

cycle 5–10

mg a day

during 4–6

months

Hyperse

nsitivity to the

preparation

components

Microniz

ed

progesterone

Utrog

estane

Fro

m the 5th

day of

menstrual

cycle 5–10

mg a day

during 4–6

months

Severe

hepatopathies,

hypersensitivit

y to the

preparation

G

onado-

tropin-

releasing

hormone

Medi

camental

castration

Triptorel

in

Diphe

reline

Fro

m the 3rd

day of

menstrual

cycle 3.75

Hyperse

nsitivity to the

preparation

components

agonists mg i.m.

every 28

days;

11.25 mg

once in 3

months up

to 6

months

Gosereli

n

Zolad

ex

3.6

mg under

the skin of

the

anterior

abdominal

wall every

28 days

during 6

months

Hyperse

nsitivity to the

preparation

components

Nafareli

ne acetate,

buserelin

Nonap

eptides

200

mcg

intranasall

y in the

morning

and in the

evening up

to 6

months

Hormon

e-dependent

tumors

G

onadotro

pin

antagoni

Pseu

domenopau

se

Danazol Danov

al, danol,

danogen

400

–800

mg/day

during 6

Porphyri

a

sts months

Gestrino

ne

Neme

stran

2.5

mg twice a

week

during 6

months

Cardiac

insufficiency,

severe hepatic

and renal

diseases,

vascular

diaseases,

dysbolism

Notes: 1) 24+4 (24-day intake, 4-day interval);

2) 42+7 ( 42-day intake, 7-day interval);

3) 126+7 (126-day intake, 7-day interval);

4) all the preparations are contraindicated in pregnancy and lactation.

Medical indications to the application of COCs (M. Silltm et al., 2001) on

prolonged schedule are endometriosis, premenstrual syndrome, dysfunctional uterine

bleedings, anemia, polycystic ovary syndrome, hemophilia, “menstrual” migraine.

Antigonadotropins cause artificial pseudomenopause. Their action consists in

blocking the release of FSH and LH, their basal secretion level being preserved.

Gonadoliberin agonists. In the last decade, there have been successfully used

such decapeptides: diphereline, decapeptyl, zoladex, and nonapeptides: buserelin,

leuprolein. These preparations have a strong antigonadotropic action and bring on

“medicamental castration”. Their application requires additional correction of

menopausal vegetovascular and metabolic disorders. The maximal term of

uninterrupted intake of the preparations makes 6 months.

Antiestrogens. Tamoxifen, toremifene (fareston) are administered only in case

of high or moderate hyperestrogenism. The dose makes 10 mg twice a day during 6

months. In hypoestrogenism tamoxifen stimulates estrogen synthesis.

Prostaglandin inhibitors. Since endometrioid foci have few estrogen- and

progesterone-binding receptors, the hormonal treatment may be ineffective.

Inactivation of these receptors is connected with a high concentration of

prostaglandins F2a in pathological implants. Therefore administration of nonsteroid

anti-inflammatory preparations, which block cyclooxygenase synthesis and increase

the sensitivity of endometriosis foci to the action of gestagens, is pathogenetically

expedient.

Enzymotherapy. There are provided independent enzymotherapy courses in

the intervals between other medicamental treatment techniques or in combination

with gestagens, and also in the rehabilitation of postoperative patients. Enzyme

preparations provide both immunomodulatory and local effects (microcirculation

improvement, edema elimination, hematoma and adhesion resorption).

Immunotherapy – systemic application of immunomodulators, which promote

endogenous production of IL-12 and gamma-interferon.

It is expedient to resort to acupuncture and hardware-controlled

physiotherapy. Physiotherapeutic procedures aim at the activation of metabolic

processes, reduction of inflammatory phenomena, prevention of hereditary process

development, restoration of regulating bonds between the control centers and target

organs of the reproductive system (laser therapy, pulse sequence ultrosund, constant

and alternating magnetic fields, iodine and zinc electrophoresis, radon baths in

hyperestrogenism, microclyster and vaginal irrigations).

In sterile women after hormonal treatment of endometriosis there is applied the

therapy aimed at hormonal disbalance correction and ovulation stimulation.

If the conservative treatment of endometriosis is ineffective, surgical

treatment is administered (laparoscopy or laparotomy).

The surgical treatment of GE has always been and remains the only technique,

which allows removing the morphological substrate of endometriosis mechanically or

eliminating it by means of laser, electrical, or thermal influence. Medicamental

therapy in the pre- and postoperative period makes it possible to optimize the results

of surgical treatment.

As for the choice of intervention volume, it is believed in recent years that even

at extensive endometriosis in women concerned with reproductive function

restoration one should follow the principles of reconstructive conservative surgery

and resort to radical operations only in the cases, when all other possibilities of both

surgical and medicamental treatment have been exhausted.

The technique and volume of surgical intervention are chosen individually.

The purpose of laparoscopic treatment is the removal of all visible foci and

restoration of normal anatomical correlations in the pelvic cavity.

The treatment of generalized and combined forms of endometriosis with

dysfunction or endometriosis affection of the adjacent organs (ureters, bowels,

urinary bladder). If endometrioid cysts are large, endometriosis is combined with

other gynecological disorders, their adequate treatment requires the application of

surgical methods, and at the same time there are no conditions to perform the

operation in full volume laparoscopically – the method of choice is laparotomy.

There are differentiated absolute and relative indications to the surgical

treatment of patients with internal endometriosis. Absolute indications include

combination of GE with diseases of the internals, which require surgical intervention

(hyperplastic processes of the ovaries and/or endometrial precancer, uterine

leiomioma, with rapid growth; severe dysplasia of the uterine neck, atypical

endometrial hyperplasia, endometrioid ovarian cysts larger than 5 cm, the ovaries

function invariably, pathological involvement of other organs and systems with their

dysfunction, suppurative involvement of the uterine appendages affected by

endometriosis, adhesive process with involvement of the ampullar parts of the uterine

tubes, which accompanies endometriosis that is the main reason for sterility;

endometriosis of the navel, endometriosis of the postoperative scar, combination of

endometriosis with some anomalies of the genital organs, a somatic pathology

excluding the possibility of continuous hormonal therapy). Among relative

indications there are differentiated the presence of asymptomatic uterine leiomyoma

in combination with atypical endometrial hyperplasia at the age younger than 40, the

3rd

degree of GE spread, ineffective medicamental treatment, which has been

uninterruptedly conducted during 6 months.

In internal 3rd

degree endometriosis (adenomyosis), when the endometrioid

tissue extends through the full thickness of the myometrium to the serosa, hormonal

treatment is ineffectual, therefore in such cases surgical treatment is indicated –

partial hysterectomy, and in endometriosis of the isthmical-cervical part – complete

hysterectomy.

At endometriosis of the uterine neck in patients of the childbearing age, if there

are solitary superficial foci, it is expedient to remove them by means of cryo- or laser

destruction followed by colposcopic monitoring and hormonal treatment.

The method of choice in the treatment of sterility must be endoscopic

interference. The advantages of this method are being minimally traumatic and with

the least blood loss, safety if one follows the rules of surgical technique and the

surgeon has sufficient experience, and also shortening of the postoperative period.

The most important advantage of this method is the visual control, which allows

complete elimination of endometriosis foci.

Electrocoagulation of solitary endometriosis foci is carried out with the use of

mono- and bipolar electrodes. Small (up to 2 cm) endometryomas are to be incised,

the doctor evacuates the contents, thoroughly enucleates the membrane of the tumor-

like formation and coagulates its bed. Sometimes in order to remove endometryoma

one resects the ovary. Endometrioid implants are often located close to the vital

organs, which creates certain difficulties for the coagulation of such implants because

of the hazard of affecting adjacent organs and anatomical structures. By indications

laparoscopic coagulation is possible and, in some cases, transaction of the

sacrouterine ligaments, which allows decreasing pain syndrome.

Treatment efficiency criteria: no relapses of the disease, reproductive

function recovery, positive dynamics of life quality.

TESTS

1.Lately menstruations at patient gained character hyperpolimenorrhea. She

complains on brown excretions and a few days after, menstruations are painful. In

history – 3 artificial abortions. Bimanual examination: the uterus is insignificaly

enlarged. A hysterosalpingography – infiltration of contrast inside the uterine wall.

Previous diagnosis?

A. endometriosis of uterus body

B. cancer of uterus body

C. myoma

D. endometriosis of uterus cervix

E. horiocarcinima

2.A patient was admitted to the hospital with complaints of periodical pain in

the lower part of abdomen that gets worse during menses, weakness, malaise,

nervousness, dark bloody smears from vagina directly before and after menses.

Bimanual examination revealed that uterus body is enlarged, appendages cannot be

palpated, posterior fornix has tuberous surface. Laparoscopy revealed: ovaries,

peritoneum of rectouterine pouch and pararectal fat have "cyanotic eyes". What is the

most probable diagnosis?

A. disseminated form of endometriosis

B. polycystic ovaries

C. chronic salpingitis

D. tuberculosis of genital organs

E. ovarian cystoma

3.A 28 year old woman has bursting pain in the lower abdomen during

menstruation; chocolate-like discharges from vagina. It is known from the anamnesis

that the patient suffers from chronic adnexitis. Bimanual examination revealed a

tumour-like formation of heterogenous consistency 7х7 cm large to the left from the

uterus. The formation I restrictedly movable, painful when moved. What is the most

probable diagnosis?

A. endometrioid cyst of the left ovary

B. follicular cyst of the left ovary

C. fibromatous node

D. exacerbation of chronic adnexitis

E. tumour of sigmoid colon

4.A 42-year-old woman has had hyperpolymenorrhea and progressing

algodismenorrhea for the last 10 years. Gynaecological examination revealed no

changes of uterine cervix; discharges are moderate, of chocolate colour, uterus is

slightly enlarged and painful, appendages are not palpable, the fornices are deep and

painless. What is the most likely diagnosis?

A. uterine endometriosis B. uterine carcinoma

C. subserous uterine fibromyoma

D. endomyometritis

E. adnexal endmetriosis

5.A 32-year-old patient consulted a doctor about being inable to get pregnant

for 5-6 years. 5 ago the primipregnancy ended in artificial abortion. After the vaginal

examination and USI the patient was diagnosed with endometrioid cyst of the right

ovary. What is the optimal treatment method?

A. surgical laparoscopy

B. anti-inflammatory therapy

C. conservative therapy with estrogen-gestagenic drugs

D. hormonal therapy with androgenic hormones

E. sanatorium-and-spa treatment

6.A 20-year-old female with Mьllerian agenesis is undergoing laparoscopic

appendectomy by a general surgeon. You are consulted intraoperatively because the

surgeon sees several lesions in the pelvis suspicious for endometriosis. You should

tell the surgeon which of the following?

A. endometriosis may arise in patients with Mllerian agenesis as a

result of coelomic metaplasia

B. endometriosis cannot occur in patients with Mьllerian agenesis since

they do not have a uterus

C. endometriosis is common in women with Mьllerian agenesis since they

have menstrual outflow obstruction

D. endometriosis probably occurs in patients with Mьllerian agenesis as a

result of retrograde menstruation

E. endometriosis cannot occur in patients with Mьllerian agenesis because

they have a 46,XY karyotype

7.A patient presents to you for evaluation of infertility. She is 26 years old and

has never been pregnant. She and her husband have been trying to get pregnant for 2

years. Her husband had a semen analysis and was told that everything was normal.

The patient has a history of endometriosis diagnosed by laparoscopy at age 17. At the

time she was having severe pelvic pain and dysmenorrhea. After the surgery, the

patient was told she had a few small implants of endometriosis on her ovaries and

fallopian tubes and several others in the posterior cul-de-sac. She also had a left

ovarian cyst, filmy adnexal adhesions, and several subcentimeter serosal fibroids.

You have recommended that she have a hysterosalpingogram as part of her

evaluation for infertility. Which of the patient’s following conditions can be

diagnosed with a hysterosalpingogram?

A. hydrosalpinx

B. endometriosis

C. subserous fibroids

D. minimal pelvic adhesions

E. ovarian cyst

8.You have just performed diagnostic laparoscopy on a patient with chronic

pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on

the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the

time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces

with the CO2 laser. But because of the extent of the patient’s disease, you

recommend postoperative medical treatment. Which of the following medications is

the best option for the treatment of this patient’s endometriosis?

A. danazol

B. continuous unopposed oral estrogen

C. dexamethasone

D. gonadotropins

E. parlodel

9.A 28-year-old nulligravid patient complains of bleeding between her periods

and increasingly heavy menses. Over the past 9 months, she has had two dilation and

curettages (D&Cs), which have failed to resolve her symptoms, and oral

contraceptives and antiprostaglandins have not decreased the abnormal bleeding.

Which of the following options is most appropriate at this time?

A. perform hysteroscopy

B. perform a hysterectomy

C. perform endometrial ablation

D. treat with a GnRH agonist

E. start the patient on a high-dose progestational agent

10.You are treating a 31-year-old woman with danazol for endometriosis.You

should warn the patient of potential side effects of prolonged treatment with the

medication. When used in the treatment of endometriosis, which of the following

changes should the patient expect?

A. lighter or absent menstruation, since danazol causes endometrial

atrophy

B. occasional pelvic pain, since danazol commonly causes ovarian

enlargement

C. heavier or prolonged periods, since danazol causes endometrial

hyperplasia

D. more frequent Pap smear screening, since danazol exposure is a risk

factor for cervical dysplasia

E. postcoital bleeding caused by the inflammatory effect of danazol on the

endocervical and endometrial glands

SITUATIONAL TASKS

1.A 39-year-old G3P3 complains of severe, progressive secondary

dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely

enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are

normal. Which of the following is the most likely diagnosis?

2.A 28-year-old woman, gravida 0, presents for evaluation of worsening

chronic pelvic pain. She had been diagnosis with endometriosis by diagnostic

laparoscopy 6 years prior but had been lost to care since that time. She reports cyclic,

left-sided pelvic pain that is no longer controlled with NSAIDs. On physical

examination, she is noted to have thickening and nodularity of her left uterosacral

ligament and her cervix is deviated to the right. She has no uterine, cervical, or right

adenexal tenderness. She is noted to have 5 cm left adenexal mass, which is tender to

palpation and fi xed to the pelvic sidewall. Transvaginal ultrasound demonstrates a

4.5-cm complex left ovarian cyst consistent with an endometrioma. The next best

step in management of this patient is:

3.A 36-year-old woman, gravida 0, with a history of endometriosis noted at a

laparoscopy performed for pelvic pain 5 years ago presents for a second opinion for

evaluation of worsening pelvic pain. Her endometriosis has been poorly controlled

with combined oral contraceptives. Over the past 8 months she has noted worsening

dysmenorrhea, dyspareunia with deep penetration, and increased constipation. She

also states that her endometriosis is making her urinate two to three times a night. She

has been taking NSAIDs maximum dose daily with little relief. She has taken GnRH

agonists in the past year for treatment for endometriosis without relief of her

symptoms. Your next step would be:

4.A 40-year-old woman, gravida 3, para 3, presents for severe central

dysmenorrhea, 8/10 in severity associated with menorrhagia. Her pain is

nonradiating, she has no exacerbating or mitigating factors. She fi nds little relief

with NSAIDs. Her pain has been getting progressively worse since the cesarean

delivery of her last child, 2 years prior. That delivery was complicated by

chorioamionitis, endometritis, and subsequent wound infection. Transvaginal

ultrasound demonstrated an 11-cm enlarged uterus without obvious pathologic fi

ndings. MRI of the pelvis is signifi cant for adenomyosis. The patient reports that she

has completed her childbearing. All of the following her appropriate plans of care

except:

5.A 32 y.o. woman consulted a gynecologist about having abundant long

menses within 3 months. Bimanual investigation: the body of the uterus is enlarged

according to about 12 weeks of pregnancy, distorted, tuberous, of dense consistence.

Appendages are not palpated. Histological test of the uterus body mucosa:

adenocystous hyperplasia of endometrium. Optimal medical tactics: