Diagnosis

Endometriosis

Etiology

Cause [1hn][43s]

• Unknown, but several theories

• Hypothesis of retrograde menstruation reflux: transport of endometrial cells through through the fallopian tubes and deposit on the pelvic organs, where they seed and grow

• Hypothesis of metaplasia: Differentiation of parietal peritoneum epithelium into endometrial tissue under the stimuli of cytokines and growth factors of the endometrial stroma

• Müllerian remnant theory: atypical migration or differentiation of remnants could imitate endometriotic tissue

• Lymphatic and vascular metastasis theory: endometrial tissue infiltrate the lymphatics and vasculature and get transferred to remote foci like the brain or the pleura

• Stem cell theory: endometrial stem cells responsible for the development and progression of endometriosis

Pathophysiology

1. Ectopic estrogen-dependent endometrial tissues respond to cyclic hormonal fluctuations with proliferation, secretions, and cyclic sloughing of menstrual material

2. Cyclic release of cytokines and prostaglandins

3. Cyclic inflammatory response characterized by neovascularization and fibrosis

4. Clinical consequences: Pain, adhesion formation, and anatomic distortion

Common sites of involvement [43s]

• Ovaries, fallopian tubes, vagina, cervix, Posterior cul-de-sac, Broad ligament, Uterosacral ligament, rectovaginal septum, Rectosigmoid colon, Bladder and Distal ureter.

• Unusual implantation sites: laparotomy scars, pleura, lung, diaphragm, kidney, spleen, gallbladder, nasal mucosa, spinal canal, stomach, breast, pericardium, or the central nervous system

Risk factors

• Family history

• Early menarche

• Long duration of menstrual flow > 7 d

• Heavy bleeding

Complications [43s]

• Chronic pain

• Infertility

Epidemiology

Incidence per 100.000 [3bn]

Prevalence per 100.000 [3bn]

Approach

• Blood test

• CA-125

• Urine stix

• HCG

• Transvaginal ultrasound

• Laparoscopy

• Biopsy

• Cervical Gram stain and culture

• CT pelvis

• MRI

• Hysterosalpingography

Treatment

Pharmacologic care: [1hn]

• Combination oral contraceptive pills

• Danazol

• Progestational agents

• Gonadotropin-releasing hormone analogues

Surgical care: [1hn]

1. Conservative - When reproductive potential is retained

   • Drainage and laparoscopic cystectomy

   • Ablation

   • Presacral neurectomy

   • Laparoscopic uterine nerve ablation

2. Semiconservative - removal of reproductive organs but ovarian function is retained (for women who have completed childbearing, but are too young for menopause)

   • Hysterectomy

   • Cytoreduction of pelvic endometriosis

3. Radical - removal of reproductive and hormonal organs

   • Total hysterectomy with bilateral oophorectomy and cytoreduction of visible endometriosis

Differential diagnoses

Adenomyosis, Appendicitis, Chlamydia, Constipation, Crohn disease, Diverticulitis, Dysmenorrhea, Gonorrhea, Interstitial cystitis, Irritable bowel syndrome, Myoma uteri, Ovarian torsion, Pelvic inflammatory disease, Ruptured ectopic pregnancy, Ruptured ovarian cyst, Ulcerative colitis, Urinary tract infection