ENDOMETRIOSIS

Endometriosis definition

The presence of endometrial tissue in extrauterine locations .

Endometriosis - pathogenesis

The exact pathogenesis is unknown

Three major theories:

1. Theory of the implantation (Sampson´s theory) – direct implantation of endometrial cells, typically by means of retrograde menstruation.

Endometriosispathogenesis

2. Coelomic metaplasia of multipotential cells in the peritoneal cavity (Meyers theory) states that, under certain conditions m-p cells can develop into endometrial tissue

3. Vascular and lymphatic dissemination of endometrial cells (Halbans theory) – distant sites of endometriosis can be explained by this process ( lymph nodes, pleura, kidney)

• Adenomyosis

(endometrial tissue in uterine wall)

• Adenomyoma

(endometrial tissue in uterine myomas)

• Endometriosis in the wall of uterine tube

Endometriosis division by Semm

Internal endometriosis of genital organs

Endometriosis division by Semm

External endometriosis of genital organs:

• Ovary: - endometrioma

(the endometrial tissue deeply in ovary tissue as a tumor)- on the surface of ovary.

• Uterosacral ligaments, round ligament of the uterus.• Uterine tubes

Endometriosis division by Semm

External endometriosis of genital organs:

• Anterior et posterior cul-de-sacs

• Pelvic peritoneum over uterus

• Uterine cervix

• Fornix of the vagina, vagina

• Perineum

Endometriosis division by Semm

Extragenital endometriosis

• Sigmoid colon, ampula of the rectum, cecum, appendix

• Urinary bladder• Umbilicus• Postoperative scars

(laparotomia, cesarean section)

Endometriosis division by Semm

Extragenital endometriosis

• Omentum• Small intestine• Femoral canal• Arms, legs• Lungs, pleura• Brain• Kidney

Endometriosis the most common sites

• Surface of the ovary – 60 – 70%• Endomerioma (ovary) – 30-40%• Peritoneum over the uterus – 40-50%• Uterine tube and mesosalpinx – 20 – 30%• Posterior cul–de–sac - 20- 30%• Uterosacral ligaments - 20-25%• Rectosigmoid - 7-10%

Endometriosis symptoms

• Pelvic pain• Dysmenorrhea• Dyspaurenia• Dysuria, hematuria• Dyschesia, rectal bleeding• Abnormal bleeding

(irregular menstrual periods, premenstrual spotting)

Endometriosis complications

• Infertility

• Abortions

• Acute abdominal emergency (rupture or torsion of an endometrioma)

Infertility

• In the group of infertile women the endometriosis occurs in 30-50%

• In the group of women with the endometriosis infertility occurs in 30-70%

The higher stage of endometriosis –

the lower chance of pregnancy.

Infertilityreasons

• Distortion of the elements of the reproductive tract and damage to the ovary (obstruction of the uterine tube, adhesions, cysts)

• Functional infertility (the influence of prostaglandin, IL-5, IL-6, complement: C3,C4 macrophages, LT helper, LT supresors, NK - anovulation, luteal phase inadequacy, phagocytosis of sperm, oocytes, unproper conditions to the implantation

Endometriosis the risk factors

• Congenital anomalies that promote retrograde menstruation

• Short period, long lasting menstruation

• Dysmenorrhea

• Infertility

• First and second degree relatives have had endometriosis

Endometriosis diagnosis

• Anamnesis • Physical examination• Laboratory studies are not useful at making

the diagnosis but helpful in the differential diagnosis

• Pelvic ultrasound• Laparoscopy• Histopathological examination

Endometriosis diagnosis

• Establishing a diagnosis requires direct visualisation at the time of the diagnostic laparoscopy or the laparotomy

• Histopatological confirmation of endometriosis is „the gold standard”

Laparoscopy / Laparotomydescription of the lesions

• Peritoneum: vascular hemorrhagic areas, white - opaque plaques, spots described as „mulberry” or „raspberry”, fibrosis surrounding these lesions, adhesions

• Ovary : endometriomas – filled with thick, chockolate-appearing fluid; superficial implants

• Uterine tubes: tubal occlusion, adhesions, distortion

• Uterus: superficial implants, retroverted and fixed

Endometriosisstaging

Classification system by the AFS • Stage I – minimal 1-5• Stage II – mild 6-15• Stage III – moderate 16-40• Stage IV – severe >40• Evaluation of areas of endometriosis

(size,localization); adhesions (types, localization), posterior cul-desac obliteration, tubal occlusion

Endometriosis differential diagnosis

• Abdominal pain ( PID, GI dysfunction, adhesions, tumors)

• Dysmenorrhea• Dyspaurenia

(PID, colpitis, uterine retroversion)

• Abnormal bleeding

(hormonal dissfunction, polyps, cervical lesions)

Endometriosis differential diagnosis

• Acute abdominal emergency (ectopic pregnancy, adnexal torsion,

rupture of corpus luteum, acute PID – peritonitis)

• Dysuria, dyschesia, hematuria, rectal beeding, hemoptysis, tumor in the scar - rare symptoms

Endometriosistreatment

The choice of therapy depends on

• Presenting symptoms and their severity

• Location and severity of endometriosis

• Desire for future childbearing

Endometriosistreatment

3 stages of the treatment by Semm• I stage: laparoscopy - surgical tratment:

electrocoagulation of endometriosis, removal of the cysts and adhesions

• II stage: medical therapy 3 – 6 months

• III stage: surgical therapy – removal of remaining endometriosis, salpingoplasty

Endometriosismedical therapy

3 groups of medicines:1. Danazol

2. Progestins

3. Gonadotropin-releasing hormone agonists

Progestinsendometriosis treatment

• Medroxyprogesterone acetate

Provera tb 20 – 40 mg/d

• Depomedroxyprogesterone acetate

Depo-Provera inj. i.m. 100 mg / 2 weeks – 8 weeks,

than 200 mg/1 month

Progestinsendometriosis treatment

Progestins supress FSH/LH release and ovarian steroidogenesis

„a state of pseodopregnancy”

Progestins endometriosis treatment

• Adverse effects: nervous system - depresion, headache, vertigo, nervosity;

skin - oily skin, itch, hirsutism;

mastalgia, nausea, weight gain;

thrombosis, alterations of lipoprotein, glucose and Ca and P metabolism

Danazol endometriosis treatment

• Danazol-17α-ethinyl testosterone derivative

tb 600 - 800 mg/d – 1 month, than 400 mg up to 6 months

• Supresses FSH/LH release and steroidogenesis endometrial atrophy

„a state of pseudomenopause”

Danazol endometriosis treatment

• Adverse effects: hypoestrogenic and androgenic properties: acne , oily skin, hirsutism, spotting, bleeding, hot flushes, atrophic vaginitis nausea, depresion, nervosity, headache, vomit, alterations of lipoprotein, glucose, Ca and P metabolism

GnRh agonists endometriosis treatment

• Triptorelin –

Decapeptyl depot a 3.75 mg inj i.m. 1x/28d,

Dipherelinum SR a 3.75 mg inj i.m. 1x/28d

• Goserelin –

Zoladex a 3.6 mg inj s.c 1x/28d

Therapy 3 – 6 months

GnRh agonists endometriosis treatment

• Pituitary desensybilisation supress FSH/LH release

„a state of pseudomenopase”

GnRh agonists endometriosis treatment

• Adverse effects:

hypoestrogenic propierties without androgenic effects

• The most expensive therapy but the most effective one