EndometriosisUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

Objectives for Endometriosis Describe the theories of pathogenesis of

endometriosis

List the most common sites of endometriosis

Describe the symptoms and physical exam findings in a patient with endometriosis

Describe the diagnosis and management of endometriosis

Benign condition in which endometrial glands and stroma are present outside the uterine cavity and walls

Definition

Prevalence of endometriosis in general population unknown

Estimated 5-15% of women have some degree of disease

Found in 1/3rd or more women with chronic pelvic pain, depending on practice setting

Typical patient is in her 30’s, nulliparous, and infertile, but can present throughout the reproductive years.

Occurrence

Retrograde menstruation (Sampson’s Theory) Endometrial fragments transported through fallopian tubes at time

of menstruation and implant at intraabdominal sites

Müllerian (Coelomic) metapalasia theory (Meyer’s Theory) Metaplastic transformation of pelvic peritoneum

Lymphatic spread (Halban’s Theory) Substances released/shed from endometrium induce formation of

endometriosis

Theories of Pathogenesis

However, since retrograde menstruation is essentially universal, host factors must impact the development of

“disease”, such as:• variations in the ability to “clean up” menstrual debris, probably reflecting immunologic events.

•Genetic differences in the tendency to develop painful conditions

•Medical and psychological comorbidities

Theories of Pathogenesis

Ovary (most common) Cul-de-sac Uterosacral ligaments Broad ligament Fallopian tubes Round ligaments Vagina Rectosigmoid and bowel, appendix Urinary bladder and ureters

Sites of Occurrence

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel, Chapter 25 (p299).

Classic Triad - dysmenorrhea, dyspareunia, dyschezia Pain (cyclic and non-cyclic) Infertility Secondary dysmenorrhea Premenstrual and postmenstrual spotting (in about

20%)

Symptoms

No pathognomonic finding Don’t forget the recto-vaginal exam! Cul-de-sac nodularity and tenderness Uterosacral nodularity Tender, fixed adnexal mass Uterus fixed and retroverted

Physical Exam

Chronic pelvic inflammatory disease Recurrent acute salpingitis Hemorrhagic corpus luteum Benign or malignant ovarian neoplasm Ectopic pregnancy

Differential Diagnosis

Sine qua non – sharp, firm, exquisitely tender “barb” (barbed wire) in uterosacral ligaments

Ultrasound – adnexal mass of complex echogenicity, internal echoes consistent with blood

Definitive diagnosis Direct visualization (via laparotomy or laparoscopy) Histologic and gross findings consistent with endometrial tissue

Other tests Ca125 - not specific nor sensitive

Diagnosis

Pathology

Appearance of endometriosis with back raised lesions of active endometriosis at the time of laparascopy

Note: Lesions may be raised or flat with red, black or brown coloration; fibrotic scarred areas that are yellow or white in hue; or vesicle that are pink, clear, or red.

Pathology

Multiple endometrial cysts “chocolate cysts”

of the ovary

Pathology

Endometrial stroma

Endometrial glandHemorrhage

Staging

American Society for Reproductive Medicine revised classification of endometriosis, 1985. (American Fertility Society: Revised American Fertility Society Classification for Endometriosis. Fertil Steril 43:351,1986)

There is no clear relationship between stage and frequency and severity of pain

symptoms

Key considerations: Severity of the symptoms Extent of the disease Desire for future fertility Age of the patient Threat to GI or urinary tract

Management

1st line treatment (adequate trial of 3-6 months) NSAIDS OCP’s , cyclic or continuous Progestins (i.e. Medroxyprogesterone acetate)

Depression, loss of bone calcium To move beyond these, strongly consider laparoscopy to both

diagnose and treat the disease.

Management (Medical)

Medical treatment2nd line treatment

Mirena IUD (levonorgestrel) GnRH agonists (Lupron); should not be done without

laparoscopy first; relief of pain does not make the diagnosis of endometriosis

Cause hot flashes, vaginal dryness, bone loss High dose progestins – suppress gonadotropin release

Cause abnormal bleeding, depression, fluid retention, nausea Danazol – androgenic derivative which suppresses LH and FSH

“Pseudomenopause” – anolvulation and hypergonadism Cause weight gain, hirsutism, acne, deepening voice Previously “gold standard,” used rarely now given side effect profile

Fertility preserving Laparoscopic (or rarely, laparotomy) with ablation or excision

of endometrial implants and adhesions Endometriomas >3 cm in diameter should be removed

surgically

Most definitive Hysterectomy (most often laparoscopic) with ablation or

excision of all endometrial implants and adhesions. Removal of ovaries has been traditional, but newer studies

suggest retention of ovaries is reasonable in many cases. Always a risk of recurrence!

Management (Surgical)

Bottom Line Concepts Typical patient with endometriosis is in her reproductive years, and sub-

fertile. Pathogenesis of endometriosis is not completely understood and

believed to be a combination of factors. Characteristic triad of symptoms associated with endometriosis is

dysmenorrhea, dyspareunia, and dyschezia. Staging of endometriosis is not clearly associated with frequency and

severity of pain symptoms. Appropriate treatment varies widely and should take into consideration

severity of symptoms, extent of disease, and desire for future fertility. There is a risk of recurrence of endometriosis throughout a woman’s

life. In all women, minimization of menstrual flow and suppression of

ovarian cycling can reduce the risk for endometriosis.

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 38 (p80-81).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 29 (p269-276).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 25 (p298-303).