Friday, February 24, 2012

ENDOMETRIOSIS and ADENOMYOSIS

Introduction
  • Common gynecological problem
  • Affect reproductive age group
  • Difficult to treat
  • Adolescents girls – mullaerian anomaly
  • Postmenopausal - HRT
DEFINITION

Presence of viable Endometrial tissue
(Glands surrounded by stroma)
outside the uterine cavity.


Sites of endometriosis

Pelvic and extra pelvic





Endometriosis of POD-(pouch of douglas)

Endometriosis of peritoneum

Ruptured endometriotic cyst

Ectopic Endometrial tissue

Tissue Contents

Endometrial Glands


Endometrial Stroma surrounding the glands

Character

Respond to hormonal stimulation

Benign tissue that invades other surrounding tissues

Menstruation within the ectopic endometrial tissue

Inflammatory response

Fibrosis


Endometriosis Theories
  1. Implantation theory (sampson)
  2. Coelomic metaplasia theory
  3. Scar endometriosis

Other factors
  1. Immunological
  2. Genetic
  3. Hormonal



Samson’s Implantation theory:
  1. Reflux of endometrial tissue
  2. Endometriosis in girls with cryptomenorrhoea

Scar endometriosis-following
  1. Classical Caesarean section
  2. Hysterotomy
  3. Myomectomy.
  4. Episiotomy

Unusual sites:
  1. Umbilicus,
  2. Ureters,
  3. Lung,
  4. Pleura,
  5. Episiotomy scar
  6. Extremities

Hormonal Influence

+ Estrogen

- Progseteron

Evidences:

Pregnancy causes atrophy of endometriosis
Regression following oophorectomy and irradiation
Rarely before puberty and after menopause

Sites

Usual sites

Lower pelvis
Cul-de-sac
Uterosacral ligaments
Peritoneum over bladder
Back of uterus
Ovaries
Sigmoid / Appendix

Surgical sites

Episiotomy

Cx stump

Abdominal scar after uterine surgery

Gross appearence

Small black dots (Gun Powder Burns)
Scarring and puckering
Yellowish brown fluid in peritoneal cavity

Chocolate cysts of ovary

Macroscopy

Vascular red adhesions on surface of ovary

Inner surface of cyst wall is vascular with dark brown tissue

Microscopy

Endometrial glands & stroma

Granulation tissue

Hemosiderin laden phagocytic cells

Laproscopic findings

Powder Burn-puckered black spots
Red vascular
Bluish/blackish/chocolate cysts
Dense adhesions in pelvis
Yellow brown peritoneal fluid
Early lesions-red flame like raised areas

Clinical Features

Asymptomatic

Menorrhagia/Polymenorrhoea.

Dysmenorrhoea

Dyspareunia
Dysuria

Dyschezia and tenesmus

Infertility tubal blockage/ovulation dysfunction

Acute abdomen (rupture of chocolate cyst)

Chronic Pelvic Pain

Dysuria, Hematuria, Hematochezia, Hemoptysis

Physical Findings
  • P/A: Cystic swelling-simulates an ovarian tumor (Chocolate cyst)-fixed, tender
  • P/V: Tender fixed R/V uterus, Adnexal mass, POD-Nodular

Endocrinology Abnormalities
  1. Anovulation
  2. Abnormal follicular development
  3. Luteal insufficiency
  4. Premenstrual spotting
  5. Lutenized unruptured follicle

D/D

PID
Ovarian tumours(benign+malignancy)
Rectal carcinoma
Acute abdomen

Investigations

USG
is not much of help because small lesion can not be detected. Useful in case of chocolate cyst of ovary.
Laparoscopy
lesions can be seen and tissue biopsy as well as treatment can be done.
Diagnosis is only by HPE examination.
Ca 125

Endometriosis vs. PID

Endometriosis
  1. Pelvic pain
  2. Congestive dysmen.
  3. Menorrhagia
  4. Sterility
  5. Response to hormones

PID
  1. Pelvic pain
  2. Congestive dysmen.
  3. Menorrhagia
  4. Sterility
  5. Response to antibiotics

Basis of treatment

Depends on
symptoms
Age
Desire to conceive
Need for conserving reproductive function
Extent of Disease
Response to Medical treatment

Objectives of Rx

To give comfort from disease

Facilitate child bearing

Treatment

For pain

For mass

For infertility

1.Expectant
2.Medical
3.Surgical
-conservative
-Radical
4. Combined

Management plan


Medical Treatment

Drug
  • Oral contraceptive pills
  • Progestogens
  • Androgens
  • GnRH analogues

Combined OCPs

1. Continuous 2tabs per day may need to increase for 6-9 months

Warnings; High incidence of side effects, risk of thromboembolism


Oral progestogens

Mode of action: Antiestrogenic effect. Continuous administration– endometrial atrophy

Duration: 6 to 9 months daily


Medroxyprogesterone acetetate
  • Dose– Given Intramuscular
  • Long acting depot preparation
  • 100mgs im every two weeks—3 months
  • 200mgs monthly for 3 to 6 months
  • ORAL- 30mgs daily

Results of Progestational Agents

50 to 70% symptomatic relief

SIDE EFFECTS: Weight gain

Irregular bleeding. Reduced libido. Mental depression. Breast tenderness.

Danazol

Synthetic derivative of Ethinyl testosterone
Action: Inhibits Pituitary gonadotrophins
Also, mildly anabolic, antioestrogenic and anti progestational
Effective though expensive
Dose: 200 to 800mgs daily for 6 to 8 months-start on first day of menses
If > 8 months symptoms of menopause
Lesions regress but side effects
Weight gain, hirsuitism, sweating, muscle cramps, depression, atrophy of breasts and vaginal epithelium, liver and renal damage

Antinflammatory drugs

Mefenamic acid 500mgs thrice a day


Helps dysmenorrhoea in 70 to 80% patients

GnRH

Gonadotrophin releasing hormone-
given continuously to supress pituitary
gonadotrophins --- causes atrophy of the endometriotic tissue
Cost is a limiting factor
Ablation of endometriotic implants <3cms Laparoscopy

Methods:

Diathermy

CO2 vaporization

laser

SURGERY

For advanced cases/larger lesions
Procedures
  1. Dissection/excision of chocolate cyst
  2. Salphingo-ophorectomy
  3. Abdominal hysterectomy
+
Pre/post operative medical Rx

ADENOMYOSIS

Islands of endometrium (endometrial glands surrounded by stroma) found in the myometrium
Uterus up to14 wks size


Diffuse, non-capsulated involvement of myometrium with tiny dark haemorrhagic areas interspersed in between.


Symptoms
  1. Parous around 40 yrs
  2. Menorrhagia, increasing dysmenorrhoea
  3. Pelvic discomfort
  4. Backache
  5. Dyspareunia

Diagnosis
  1. Symmetric enlargement of uterus (seldom>14 wk)
  2. Menorrhagia
  3. Dysmenorrhoea

Surgery is the treatment of choice


Final diagnosis is on the histopathology

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