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EndometriosisEMTDefinitionEndometriosisisadisorderinwhichabnormalgrowthsoftissue,histologicallyresemblingtheendometrium,arepresentinlocationsotherthantheuterinelining.
Thelesionsareusuallyfoundontheperitonealsurfacesofthereproductiveorgansandadjacentstructuresofthepelvis,buttheycanoccuranywhereinthebody.Itsexactprevalenceisunknownbecausesurgeryisrequiredforitsdiagnosis,butitisestimatedtobepresentin10%ofallreproductiveagewoman.ImplantationtheoryRetrogrademenstruationIatrogenicimplantLymphaticandvasculardisseminationMetaplasiatheoryofcoelomicepitheliumInductiontheoryEtiologyThesizeoftheindividuallesionsvariesfrommicroscopictolargeinvasivemassesthaterodeintounderlyingorgansandcauseextensiveadhesionsformation.PathologyOvarianendometriosisPeritonealendometriosisDeepinfiltratingendometriosispathologyOvarianEMTbilateralovariesinvolvedin50%casesmicrolesionsmacrolesions-----chocolatecyst(endometrioma)pathologyPeritonealEMTUterosacralligament,Cul-de-sacandposterialwalloftheuterusDeepinfiltratingEMTUterosacralligament,Cul-de-sac
pathologyMicroscopyendometrialglandendometrialstromaorhemosiderin-ladenmacrophagespathologyClinicalfindingsvarygreatlydependingonthenumber,size,andtheextentofthelesions.WomenwithEMTcanbecompletelyasymptomaticormaybecrippledbypelvicpainandinfertility.ClinicalpresentationChronicpelvicpainanddysmenorrhea:constantpelvicpainoralowsacralbackachepremenstruallyandsubsidesaftermensesbeginsDyspareuniaClinicalpresentationInfertilityAnatomicabnormalityofpelviccavityChangeofthemicroenvironmentofthepelviccavityAbnormalimmunefunctionOvariandysfunctionClinicalpresentationAbnormalmenstruation
-Menorrhagia-premenstrualspottingOtherlocalizationurinarytract:bloodyurinebowel:bloodystoolscar(episiotomyandcesareansectionincision)ClinicalpresentationPelvicexaminationtenderadnexalmassuterusfixedandretrovertedtendernodulesinuterosacralligament,cul-de-sacandposterialwalloftheuterusClinicalpresentationClinicalpresentationUltrasonicexaminationSerumCA125determinationlaparoscopydiagnosisPelvictumorsPelvicinflammatorydiseaseAdenomyosisDysmenorrheausuallythiswillrequireoperativeevaluationDifferentialdiagnosisTreatmentoptionsaredictatedbythepatient’sdesireforfuturefertility,hersymptoms,thestageofherdisease,andtosomeextentherage.Itmustbeemphasizedthattherapiesrequireoperativeinspectionofthelesionsforcorrectdiagnosis.treatmentObservationAnalgesictherapyMedicine:pseudopregnancypseudomenopausegestrinoneothertherapy:mifepristonesurgerytreatmentInasymptomaticpatients,thosewithmilddiscomfort,orinfertilewomenwithminimalormildendometriosis,expectantmanagementmaybeappropriate.treatmentobservationWhenthepatienthasmildpremenstrualpainfromminimalEMT,noabnormalitiesonpelvicexamination,andnodesireforimmediatefertilityProstaglandinsynthetaseinhibitingdrugstreatmentAnalgesictherapyPseudopregnancyBestreservedforpatientswithmilderformsofEMTwhodonotdesireimmediatefertilityandareunabletotakeothertreatments.Createconstanthighlevelsofprogestins,asseeninpregnancy,tothintheendometriumandcauseitsregressionwithpseudodecidualchanges.treatmentMedicinePseudopregnancyOralcontraceptionProgestin
Sideeffect:depression,bloating,weightgain,breakthroughbleedingtreatmentMedicinePseudomenopauseGn-RH(gonadotropinreleasinghormone)agonistsmedicallyoophorectomySideeffect:perimenopusesymdromeosteoporosis,hecticfeveradd-backtherapytreatmentMedicinePseudomenopauseDanazol:aweakandrogeninhibitGn-RHreleasingsexsteroidsbindtoandrogenreceptorsanddirectlyinhibitimplantgrowthSideeffect:acne,oilyskin,deepeningofthevoice,weightgain,edema,andadverseplasmalipoproteinchanges(androgenic)
treatmentMedicineOtherhormonaltherapiesGestrinoneItisananti-estrogen,anti-progesteronesteroidwitheffectssimilardanazol.Thedoseis2.5-5mgorallytwiceweekly.Followupliverfunction
treatmentMedicineIndicationmedicaltreatmentineffectiveovaryendometrioticcystlargerthan5cmdesireforfertilitytreatmentsurgeryPreservereproductiveability:conservativesurgery,exciseordestroyallendometriotictissue,removealladhesions,andrestorepelvicanatomyPreserveovarianfunction:doesnotdesirefuturechild-bearingtreatmentStyleofoperationradicalsurgery:totalhysterectomy,bilateralsalpingooophorectomy,andexcisionofremainingadhesionsorimplantationSurgerytorelievepain:presacralneurectomyoruterosacralligamenttreatmentStyleofoperationPreventretrogradeofmenstruationPa
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