1. ENDOMETRIOSIS
Dr. Yashika

2. Definition
 Presence of functioning endometrium
(glands and stroma) in sites other than
uterine mucosa is called endometriosis.
 It is a benign but it is locally invasive.

3. Prevalence
 The real one is due to delayed marriage,
postponement of first conception and adoption
of small family norm.
 The apparent one is due to increased use of
diagnostic laparoscopy as well as hightened
awareness of this disease complex amongst
the gynecologists

4. Sites
 Abdominal: Usually confined to the
abdominal structures below the level of
umbilicus.
 Extra-abdominal: Common sites are
abdominal scar of hysterotomy, cesarean
section, tubectomy and myomectomy,
umbilicus, episiotomy scar, vagina and cervix.
 Remote

5. Pathology
 Naked Eye Appearance: The appearance of
the lesion depends on the organs involved,
extent of lesion and reaction of the surrounding
tissues.
 Pelvic endometriosis: Small black dots, called
‘powder burns’ seen on the uterosacral
ligaments and pouch of Douglas.
 Fibrosis and scarring

7. Symptoms
 Dysmenorrhea (70%)
 Abnormal menstruation (20%)
 Infertility (40–60%)
 Dyspareunia (20–40%)
 Chronic Pelvic Pain
 Abdominal Pain

8.  Urinary— frequency, dysuria, back pain or even
hematuria.
 Sigmoid colon and rectum—painful defecation
(dyschezia), diarrhea, constipation, rectal bleeding or
even melena.
 Chronic fatigue, perimenstrual symptoms (bowel,
bladder).
 Hemoptysis (rarely), chest pain.
 Surgical scars—cyclical pain and bleeding.

9. Examination
Abdominal palpation
 A mass may be felt in the lower abdomen arising from the
enlarged tubo-ovarian mass due to endometriotic
adhesions. The mass is tender with restricted mobility.
Pelvic Examination
 Pelvic tenderness, nodules in the pouch of Douglas,
nodular feel of the uterosacral ligaments, fixed uterus or
unilateral or bilateral adnexal mass of varying sizes

10. Diagnosis
Bichemical parameters:
 Serum CA 125
 Monocyte Chemotactic Protein (MCP-1)
Imaging:
TVS - ovarian endometriomas
Endorectal USG - Rectosigmoid endometriosis
MRI - deep infiltrating endometriosis.
Colonoscopy, rectosigmoidoscopy and cystoscopy

11. Differential Diagnosis
 Chronic pelvic infection / symptomatic endometriosis.
Laparoscopy is helpful in actual diagnosis.
 Ovarian endometrioma / benign ovarian tumor /
malignant ovarian.
Ultrasonography or Laparoscopy
 Rupture of the chocolate cyst / torsion or rupture of the
ovarian tumour, disturbed ectopic pregnancy,
appendicitis or diverticulitis.

12. Complications
 Endocrinopathy
 Rupture of chocolate cyst
 Infection of chocolate cyst
Obstructive features:
 Intestinal obstruction
 Ureteral obstruction → hydroureter
 hydronephrosis → renal infection

13. Endocrinopathy in Endometriosis
 Corpus luteum insufficiency
 Luteolysis due to ↑ PGF.
 ™
Luteinized unruptured follicle (LUF)
 Anovulation
 ™
Elevated prolactin level
 Double LH peak.

14. Staging
Endometrios is should be staged appropriately.
 To predict prognosis.
 To choose therapy.
 To evaluate the treatment protocol.
The stage is determined by adding specific
points given to each.

15. American Fertility Society scoring
system of endometriosis (revised)
Peritoneum
Endometriosis < 1 cm 1–3 cm > 3 cm
Superficial 1 2 4
Deep 2 4 6
Ovary
R Superficial 1 2 4
Deep 4 16 20
L Superficial 1 2 4
Deep 4 16 20
Posterior
cul-de-sac
obliteration
Partial Complete
4 40

16. Ovary
Adhesions < 1/3
Enclosure
1/3–2/3
Enclosur
e
> 2/3
Enclosur
e
R Filmy 1 2 4
Dense 4 8 16
L Filmy 1 2 4
Dense 4 8 16
Tube
R Filmy 1 2 4
Dense 4* 8* 16
L Filmy 1 2 4
Dense 4* 8* 16
* If the fimbriated end of the fallopian tube is completely
enclosed, change the point assignment to 16.

17. Stage Severe Score
I Minimal 1-5
II Mild 6-15
III Moderate 16-40
IV Severe >40

18. Treatment
Preventive
• To avoid tubal patency test
• Avoiding pelvic examination
should not be done during or
shortly after menstruation.
• Married women with family
history are encouraged to
complete the family.
Curative
• To minimize pelvic pain
and dyspareunia
• To improve the fertility
• To prevent recurrence

19. Pelvic Endometriosis
 Expectant Management (observation only)
 Medical Therapy
• Hormones • Others
 Surgery
• Conservative • Definitive
 Combined Therapy
• Medical • Surgical

20. Expectant Treatment
 Some form of treatment is often needed
regardless of the clinical profile and to
arrest the progress of the disease.
 In women with minimal to mild
endometriosis role of any treatment is
controversial.

21. Case selection for expectant treatment
 Minimal endometriosis with no other abnormal
pelvic finding
 Unmarried
 Young married who are ready to start family
 Approaching menopause

22. Protocols for Expectant
Management
 Observation
Ibuprofen 800–1200 mg
Mefenamic acid 150–600 mg.
 The married women are encouraged to have
conception.

23. Hormonal Treatment
Drugs Dose Mechanism
Combined estrogen
progestogen
1–2 tablets Pseudopregnancy
Progestogens
Oral
• Medroxyprogesterone
acetate
10 mg TDS Pseudopregnancy
• Dydrogesterone 10–20 mg daily
• Norethisterone 10–30 mg daily
IM
• Medroxyprogesterone
150 mg 3 months
IUCD
• Levonorgestrel-
releasing-IUCD

24. Danazol 400–800 mg orally in 4
divided
doses × 6–9 months
Pseudopregn
ancy
Gestrinone 1.25 or 2.5 mg twice
a week × 6–9 months
Pseudopregn
ancy
GnRH
analogues
Leuprolide 3.75 mg IM
monthly × 6 months
• Naferelin 200 μg
intranasally daily × 6
months
• Goserelin 3.6 mg depot
IM
monthly × 6 months
Medical
oophorectomy

25. Surgical Management
Indications
 Endometriosis with severe symptoms
unresponsive to hormone therapy.
 Severe and deeply infiltrating endometriosis to
correct the distortion of pelvic anatomy.
 Endometriomas of more than 1 cm.
 Surgery may be conservative or definitive.

26. Conservative surgery
 Done to preserve the reproductive function.
 Laparoscopy done to destroy endometriotic
lesions by excision or ablation
 Laparoscopic uterosacral nerve ablation
(LUNA) is done when pain is very severe.

27. Definitive surgery
hysterectomy with bilateral savlpingo-
oophorectomy along with resection of the
endometrial tissues as complete as possible

28. Combined Medical and Surgical
 Aims at reduction of the size and vascularity of the
lesion which facilitate surgery.
 The idea of postoperative hormonal therapy is to
destroy the residual lesions left behind after
surgery and to control the pain.
 Duration of therapy is usually 3–6 months
preoperatively and 3–6 months postoperatively.

29. ENDOMETRIOSIS AT SPECIAL
SITES
 Abdominal scar
 Umbilicus
 Bladder and ureter
 Gut
 Cervix and vagina
 Lung

30. Thank you ..