ENDOMETRIOSIS 3.
Lymphatic and Vascular Metastasis
- presence and growth of the glands and stroma of the
lining of the uterus in an aberrant or heterotopic
location
(Adenomyosis - the growth of endometrial glands and
stroma into the uterine myometrium to a depth of at
least 2.5 mm from the basalis layer of the
endometrium)
- Benign but in many women, a progressive and
aggressive disease.
TYPICAL PATIENT
- Mid 30’s
- Nulliparous
- Involuntarily infertile
- Symptoms of secondary dysmenorrhea and
- Pelvic pain (Classic symptom)
(30 NIPS)
ETIOLOGY
1. Retrograde Menstruation
-Most popular theory
-Implantation of endometrial cells shed during
menstruation and attach to the pelvic peritoneum
under hormonal influences and grow as homologous
grafts
-Usually found near the tubal ostia and dependent areas
-Common in women with outflow obstruction of the
genital tract
2. Metaplasia
-The condition arises from metaplasia of the coelomic
epithelium or proliferation of embryonic rests
-Mullerian ducts and nearby mesenchymal tissue has
multipotential ability
-Suggested by the fact that the condition can be seen in
prepubertal girls, women with congenital absence of
the uterus and very rarely in men
-May explain why 30% of women with the disease has
lymph node implants as well as in the thighs, forearms
and the lungs
4. Iatrogenic Dissemination
-Implants in the anterior abdominal wall noted in post
CS women, sometimes in episiotomy sites
5. Immunologic Factors
-Not all women with retrograde menstruation develop
endometriosis
-Disease may develop as result of reduced immunologic
clearance of viable endometrial cells from the pelvic
cavity
-Higher basal activation status of peritoneal
macrophages impair fertility by decreasing sperm
motility, increasing sperm phagocytosis, increased
secretion of cytokines and growth factors which may
facilitate pelvic implantation of ectopic endometrium
6. Genetic Factors
-Incidence is 7% greater if a first degree-relative has
been affected by endometriosis
-Multifactorial inheritance
-Associated with high incidence in mother-sister
occurrences, as well as in monozygotic twins
-Also related to auto-immune diseases (Lupus
Erythematosus)
PATHOLOGY
-Majority are located in the dependent portions of the
pelvis
-Most common site: ovaries, mostly bilateral
-Peritoneum over the uterus, anterior and posterior cul-
de-sac, uterosacral, round and broad ligaments
-Advanced disease affect rectosigmoid areas
 SYMPTOMS
PAIN
- Usually cyclical and chronic
- Secondary dysmenorrhea or dyspareunia
- Approx. absent in 1/3 of cases
-Visual manifestation is variable
- Paradoxically, pain is more often encountered in
-Color may range from black to red to pink depending
smaller lesions compared to those with large, fixed
on the blood supply and amount of fibrosis and
adnexal masses
hemorrhage as well the size, degree of edema
- Prostaglandins are the chemical mediators
-Size range from small, bleb-like implants powder burn
areas < 1 mm diameter (new lesions) to chocolate cysts
SUBFERTILITY
> 8 cm in diameter
-tubo-ovarian blockage due to adhesions and ovarian
implants
-increased resistance to the sperm (immunologic)
-increased incidence of abortion

ABNORMAL BLEEDING
-Premenstrual spotting
-Menorrhagia
- Usually not associated with an anovulatory pattern but
15 % of cases may be associated with anovulatory cycles

Less Common Symptoms

-Cyclic abdominal pain
-Intermittent constipation
-Diarrhea
-Dyschezia
-Urinary frequency
-Dysuria
-Hematuria
3 CARDINAL HISTOLOGIC SIGNS
-Catamenial hemothorax
1. Ectopic endometrial glands
PHYSICAL EXAM
2. Ectopic endometrial stroma
3. Hemorrhage into the adjacent tissues (previous - Classic pelvic finding: retroverted uterus with scarring
hemorrhages evidenced by large macrophages filled and tenderness posterior to the uterus
with hemosiderin near the periphery of the lesion) -Nodular uterosacral ligaments and pouch of Douglas
-Enlarged and tender adnexal organs
IMAGING
Ultrasound
- may be helpful in differentiating solid from cystic
lesions and may help distinguish an endometrioma from
other adnexal abnormalities.
-lesions are vascular, increased Doppler flow may be
demonstrated in endometriosis
-Fair sensitivity from 49% to 91%, with high specificity
93% to 100%
MRI
-Provides the best overall diagnostic tool for
endometriosis but is not always a practical modality for
its diagnosis.
-sensitivity and specificity of approximately 91% to 95%.
-detection ratio and specificity of around 78% for
implants
-characteristic hyperintensity on T1-weighted images
-hypointensity on T2-weighted images
DIAGNOSTIC LAPAROSCOPY
- it is important to describe systematically the extent of
the pathology.
-The American Society for Reproductive Medicine
developed a point-scoring system in 1996, designed
primarily to record the extent of the disease in fertility
patients. (ASRM, 1997)
-More recently, a proposed scoring system by Adamson
focuses on the fertility potential of patients with
endometriosis, the Endometriosis Fertility Index and it
has been shown in prospective evaluation to correlate
with pregnancy rates. (Adamson, 2010).
TREATMENT
MEDICAL THERAPY
1. Danazol
-produce a high-androgen, low-estrogen environment
(simulating follicular phase to postmenopausal range)
that does not support growth of endometriosis, and
preventing amenorrhea and seeding of implants
-“pseudomenopausal effect”
-Direct inhibition of steroidogenesis
-Increased metabolic clearance of estradiol and
progesterone
-Initialized as 200mg BID orally (up to 800 mg/daily)
with the absence of menses as a better indicator of
response
Adverse Side effects: weight gain, fluid retention, acne,
oily skin, hirsutism, hot flashes, atrophic vaginitis,
reduced breast size, reduced libido, fatigue, nausea,
muscle cramps, and emotional instability
Contraindicated in the following cases:
-liver disease (largely metabolized in the liver
-Hypertension
-CHF
-impaired renal function (fluid retention)
-Pregnancy (androgenic effects in fetus)
2. GnRH Agonists
-Bind to the pituitary GnRH receptors and stimulate FSH
and LH synthesis but have a longer biological half-life 
down regulation of GnRH agonist activity  low FSH
and LH levels
-Medically induced and reversible state of
pseudopregnancy or pseudomenopause without
androgenic effects
-Produces “medical oophorectomy”
-Side effects similar to menopause: hot flushes, vaginal
dryness, insomnia, osteopenia/porosis
-Ovarian function returns to normal in 6-12 weeks after
6 months of GnRH agonist therapy
-Leuprolide acetate (Leuprolex,injectable) – given
1.88mg-7.5 mg IM/month (3.75mg or 11.25 mg depot) –
-Nafarelin acetate (Synarel, intranasal) – 200ug bid in
bilateral nostrils
-Goserelin acetate (Zoladex, subcutaneous implant) -
3.6 mg every 28 days, biodegradable
3. Oral Contraceptives
-Low-dose monophasic combination oral contraceptive
to induce amenorrhea or “pseudopregnancy”
-1 pill/day x 6-12 months
-Any low dose combination OCP with 30-35μg of ethinyl
estradiol (+progestins)
-Reduces dysmenorrhea and pelvic pain
-SE: weight gain, breast tenderness
4. NSAIDs
-Beneficial for Pain relief
5. Other Hormonal Treatments
For older women who have completed child bearing:
-Medroxyprogesterone acetate (Provera) 20- 30mg
orally/day
-Depo-medroxyprogesterone acetate (DepoProvera)
150 (-200) mg IM/3 months
-Gestrinone 2.5-7.5 mg/week orally
EFFICACY
Pain
- all previously mentioned medications have similar
efficacy in reducing pain associated with endometriosis
Subfertility
- Conception is contraindicated or impossible
-There is no evidence that medical treatment of minimal
to mild endometriosis leads to better changes of
pregnancy than expectant management
Post-op medical treatment required in patients with
incomplete surgical resection
Disadvantages over surgical treatment
-High prevalence of side-effects
-High cost of hormone preparations
-Higher recurrence rates
SURGICAL THERAPY
-Depends on patient’s age, symptomatology and
reproductive desire
-If preservation of reproductive function is desired, the
least invasive and least expensive approach that is
effective should be used
-Removal of all macroscopic visible areas of
endometriosis with preservation of ovarian function
-Laparoscopy: bipolar coagulation, CO2 laser,
potassium-titany-phosphate laser, argon laser
-Laparotomy – reserved for patients with advanced
stage illness and for those in whom fertility is no longer
necessary
• CSEL – conservative surgery for endometriosis at
laparotomy
• PSN – presacral neurectomy
• TAH/BSO
ENDOMETRIOMAS AT OTHER SITES
1. GI Tract
2. Urinary Tract
3. Extrapelvic