Endometriosis

ENDOMETRIOSIS
Ivy Jillane T. Policarpio

Resident Trainee II
Endometriosis
 Endometriosis is a benign but a progressive and an
aggressive disease
 It is the presence and growth of the glands and

stroma of the lining of the uterus in an aberrant or
heterotopic location
Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Etiology
RETROGRADE MENSTRUATION
 Sampson suggested that pelvic endometriosis was

secondary to implantation of endometrial cells shed
during menstruation
 Discovered most frequently in areas immediately

adjacent to the tubal ostia or in the dependent areas
of the pelvis
Etiology
METAPLASIA
 Arises from the metaplasia of the coelomic

epithelium or proliferation of embryonic rests
 “induction phenomenon”  induction substance
may be a combination of menstrual debris and the
influence of estrogen and progesterone

Etiology
LYMPHATIC AND VASCULAR METASTASIS
 Hematogenous dissemination of endometrium is

the best theory to explain endometriosis of the
forearm and thigh, as well as multiple lesions in the
lung

Etiology
IMMUNOLOGIC CHANGES
 Alteration in the function of the peritoneal

macrophages so prevalent in the peritoneal fluid of
patients with endometriosis.
GENETIC PREDISPOSITION
 Familial predisposition to endometriosis with grouping
cases of endometriosis in mothers and daughters

Etiology
IATROGENIC DISSEMINATION
 Endometriosis of the anterior abdominal wall is

sometimes discovered in women after a cesarean
delivery
 The hypothesis is that endometrial glands and
stroma are implanted during the procedure
 The aberrant tissue is found subcutaneously at the
abdominal incision
PATHOLOGY
 majority of endometrial implants are located in the
dependent portions of the female pelvis
 most common site: OVARIES, usually bilateral
 pelvic peritoneum over the uterus; the anterior and
posterior cul-de-sac; and the uterosacral, round, and
broad ligaments

PATHOLOGY
 Deep lesions, penetrations of greater than 5 mm,
represent a more progressive form of the disease.
 umbilicus, areas of previous surgical incisions of the
anterior abdominal wall or perineum, the bladder,
ureter, kidney, lung, arms, legs, and even the male
urinary tract
 Ovarian endometriosis is also variable
 range from 1 mm to large chocolate cysts greater than
8 cm in diameter

PATHOLOGY
 Cardinal histologic
features of
endometriosis
 ectopic endometrial
glands
 ectopic endometrial
stroma
 hemorrhage into the
adjacent tissue

CLINICAL DIAGNOSIS: SYMPTOMS
 The classic symptoms of endometriosis are cyclic pelvic pain

and infertility
 The chronic pelvic pain usually presents as secondary
dysmenorrhea or dyspareunia
 Secondary dysmenorrhea usually begins 36 to 48 hours prior to

the onset of menses
 common component of pain that varies from a dull ache to severe
pelvic pain
 Unilateral or bilateral and may radiate to the lower back, legs, and
groin
 pelvic heaviness or a perception of their internal organs being swollen

 Cyclic pelvic pain  sequential swelling and

extravasation of blood and menstrual debris into
the surrounding tissue
 Chemical mediators of this intense sterile

inflammation and pain are:
 prostaglandins and cytokines

 Dyspareunia associated with endometriosis

 pain deep in the pelvis
 cause of this symptom is immobility of the pelvic
organs during coital activity or direct pressure on areas
of endometriosis in the uterosacral ligaments or the
cul-de-sac

 Abnormal bleeding
 most frequent complaints are premenstrual spotting
and menorrhagia
 not associated with anovulation and may be related to
abnormalities of the endometrium.
 frequently have ovulatory dysfunction
 15% of women with endometriosis have coincidental
anovulation or luteal dysfunction

CLINICAL DIAGNOSIS: PHYSICAL EXAM
Physical exam findings

 fixed retroverted uterus, with scarring and tenderness
posterior to the uterus

 nodularity of the uterosacral ligaments and cul-de-sac
 ovaries may be enlarged and tender and are often
fixed to the broad ligament or lateral pelvic sidewall

 Lateral displacement or deviation of the cervix is
visualized or palpated by digital exam of the vagina

and cervix

CLINICAL DIAGNOSIS: IMAGING
 Ultrasound
 no specific pattern to screen for pelvic endometriosis,
helpful in differentiating solid from cystic lesions
 distinguish an endometrioma from other adnexal
abnormalities
 Magnetic resonance imaging (MRI)
 provides the best overall diagnostic tool for
endometriosis

CLINICAL DIAGNOSIS:
IMAGING
 Diagnostic laparoscopy
 laparoscopy is undertaken to establish the diagnosis of
endometriosis
 Gold standard
 Provide characterization of disease extent for fertility

MONITORING THE COURSE
 Ca-125
 low specificity
 increase with other pelvic conditions
 leiomyomas, acute pelvic inflammatory disease, and the first trimester of
pregnancy
 Glycodelin/ Placental protein 14

 elevated in endometriosis and is produced in endometriotic lesions
 not specific due to variability
 The most predictive markers appear to be Il-1, chemoattractant

protein-1 and interferon gamma, with Il-1 being the most useful
marker
MONITORING THE COURSE
 Endometriosis may be associated with ovarian
cancer.
 risk of developing ovarian cancer may increase
fourfold in women with endometriosis

TREATMENT
 short-term goals in treating endometriosis are the relief of pain and promotion
of fertility
 longterm goal in the management of endometriosis is attempting to prevent

progression or recurrence of the disease process
 Choice of therapy
 for women whose primary symptom is pelvic pain, depends on:
 the patient’s age, her future reproductive plans, the location and extent of her disease, the
severity of her symptoms, and associated pelvic pathology.
 Gold standard for making a diagnosis is laparoscopy to establish the nature

and extent of endometriosis
 Empiric medical therapy for 3 months

TREATMENT
 Optimal regression secondary to medical treatment
is observed in small endometriomas that are less
than 1 to 2 cm in diameter.

TREATMENT: MEDICAL
THERAPY
DANAZOL
 Synthetic steroid that is isoxazole derivative of
ethisterone (17-α-ethinyltestosterone)
 produces a hypoestrogenic and hyperandrogenic
effect on steroid-sensitive end organs.

 induces atrophic changes in the endometrium of the
uterus and similar changes in endometrial implants

TREATMENT: MEDICAL
THERAPY
DANAZOL
 total daily dosage of the drug to 200, and even 100,
mg of danazol daily.
 begins during menses (days 1 to 5)
 standard length of treatment with danazol is 6 to 9
months

TREATMENT: MEDICAL
THERAPY
GNRH AGONIST
 leuprolide acetate (Lupron, injectable), nafarelin acetate
(Synarel, intranasal), and goserelin acetate (Zoladex,

subcutaneous implant)
 Leuprolide acetate is 3.75 mg intramuscularly once per month

or an 11.25-mg depot injection every 3 months
 Nafarelin acetate nasal spray is given in a dose of one spray
(200 μg) in one nostril in the morning and one spray (200 μg) in
the other nostril in the evening up to a maximum of 800 μg daily.
 Goserelin acetate is given in a dosage of 3.6 mg every 28 days
in a biodegradable subcutaneous implant
TREATMENT: MEDICAL
THERAPY
GNRH AGONIST
 Chronic use of GnRH agonists produces a “medical
oophorectomy.”
 three most common symptoms are hot flushes,
vaginal dryness, and insomnia.

 Amenorrhea is induced within 6 to 8 weeks
 Ovarian function usually returns to normal in 6 to
12 weeks after 6 months of GnRH agonist therapy.

TREATMENT: MEDICAL
THERAPY
ORAL CONTRACEPTIVES
 Primarily used for 6 to 12 months
 Most common side effects of inducing amenorrhea
with oral contraceptives include weight gain and

breast tenderness

TREATMENT: MEDICAL
THERAPY
A. Gestrinone
 a progestogen
 dosages ranging from 2.5 to 7.5 mg/ week
 acts as an agonist–antagonist of progesterone
receptors and an agonist of androgen receptors and

also binds weakly to estrogen receptors

TREATMENT: MEDICAL
THERAPY
B. Dienogest
 a selective progestogen that causes anovulation, has
an antiproliferative effect on endometrial cells, and

may inhibit cytokine secretion
 2 mg/day orally

TREATMENT: MEDICAL
THERAPY
C. Aromatase inhibitors
 (anastrozole 1 mg, and letrozole 2.5 and 5 mg)
 have been found to be beneficial in that not only
does estrogen tend to cause proliferation of the

disease but also endometriosis lesions have been
found to contain the aromatase enzyme

TREATMENT: SURGICAL
THERAPY
 The main roles of surgical therapy in the
management of are to provide symptomatic relief
(pain) and to improve fertility outcomes.
 Surgical management includes conservative and

definitive approaches that address three main
categories of lesions: superficial endometriosis,
endometriomas and deep infiltrating
endometriosis (DIE).

TREATMENT: SURGICAL
THERAPY
 Conservative surgery involves the resection or
destruction of endometrial implants, lysis of
adhesions, and attempts to restore normal pelvic
anatomy.
 Definitive surgery involves the removal of both

ovaries, the uterus, and all visible ectopic foci of
endometriosis.

TREATMENT: SURGICAL
THERAPY
 Definitive surgical treatment, involving
hysterectomy, is effective for symptomatic relief
with reoperation free rates of 86% (with ovarian
preservation) and 91% (without ovarian
preservation) at 5 years.

ENDOMETRIOSIS AT OTHER
SITES
 GASTROINTESTINAL TRACT
ENDOMETRIOSIS
 URINARY TRACT ENDOMETRIOSIS

GASTROINTESTINAL TRACT
ENDOMETRIOSIS
 incidence varies from 3% to 37%

 the most common site of extrapelvic endometriosis
but can be the most challenging to manage
 commonly involves the sigmoid colon and the
anterior wall of the rectum
 usually unresponsive to medical therapy and often
requires surgical excision wherein complete excision
of these lesions sometimes necessitates bowel
resection

URINARY TRACT
ENDOMETRIOSIS
 The most serious consequence of urinary tract
involvement is ureteral obstruction, which occurs in
about 1% of women with moderate or severe pelvic
endometriosis
 Surgical therapy is the preferred treatment for
ureteral obstruction secondary to endometriosis
 Most common surgical approach include removal of
the uterus and both ovaries and the relief of urinary
obstruction by ureterolysis or by
ureteroneocystostomy.
THANK YOU!!!

Endometriosis

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ENDOMETRIOSIS

Ivy Jillane T. Policarpio

 It is the presence and growth of the glands and

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Sampson suggested that pelvic endometriosis was

 Discovered most frequently in areas immediately

 Arises from the metaplasia of the coelomic

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Hematogenous dissemination of endometrium is

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Alteration in the function of the peritoneal

cases of endometriosis in mothers and daughters

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Endometriosis of the anterior abdominal wall is

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 The classic symptoms of endometriosis are cyclic pelvic pain

 Secondary dysmenorrhea usually begins 36 to 48 hours prior to

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Cyclic pelvic pain  sequential swelling and

 Chemical mediators of this intense sterile

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Dyspareunia associated with endometriosis

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Physical exam findings

posterior to the uterus

 ovaries may be enlarged and tender and are often

fixed to the broad ligament or lateral pelvic sidewall

visualized or palpated by digital exam of the vagina

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Glycodelin/ Placental protein 14

 The most predictive markers appear to be Il-1, chemoattractant

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 longterm goal in the management of endometriosis is attempting to prevent

 Gold standard for making a diagnosis is laparoscopy to establish the nature

 Empiric medical therapy for 3 months

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

effect on steroid-sensitive end organs.

uterus and similar changes in endometrial implants

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 standard length of treatment with danazol is 6 to 9

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

(Synarel, intranasal), and goserelin acetate (Zoladex,

 Leuprolide acetate is 3.75 mg intramuscularly once per month

vaginal dryness, and insomnia.

 Ovarian function usually returns to normal in 6 to

12 weeks after 6 months of GnRH agonist therapy.

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 Most common side effects of inducing amenorrhea

with oral contraceptives include weight gain and

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 dosages ranging from 2.5 to 7.5 mg/ week

 acts as an agonist–antagonist of progesterone

receptors and an agonist of androgen receptors and

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

an antiproliferative effect on endometrial cells, and

Endometriosis Comprehensive Gynecology 7th edition Chapter 19

 have been found to be beneficial in that not only

does estrogen tend to cause proliferation of the