C17 Endometriosis

Epidemiology

Prevalence

Risk and protective factors

Endometriosis and cancer

Increased risk of carcinoma at the site of endometriosis, especially in the ovary.

Etiology

????(stroma, gland)? ?? ?? ?? ?
Most likely due to retrograde menstruation with implantation at an ectopic site.

Ectopic endometrium responds to hormonal influences of the menstrual cycle.
- ??? ????, E dependent
Formation of blood collections in the ectopic locations
Over time, hemolysis and inflammation
Adhesion formation
Distorts organ structure and function.
- ??? retroversion?? ??, ??/?? ??? ??
- ??? ?? ??? ??? ?? ? subfertility

Genetic factors

Immunologic factors and inflammation

Environmental factors and dioxin

Future research

Diagnosis

CA-125 ??, ??? laparo Bx – “gun shot”, ??

Clinical presentation

TRIAD: ?? (by ??), ???, ???(dyspareunia), ~~????~~

Site	Symptom
Ovary	M/c site. ‘Endometriosis’ ??? ?? cyst = Endometrioma. “chocolate fluid”
Pouch of Douglas	Pain with defecation (dyschezia)
Bladder wall	Pain with urination (dysuria)
Bowel serosa	Abdominal pain and adhesions.
Fallopian tube mucosa	Scarring increases risk for ectopic tubal pregnancy
Myometrium	‘Adenomyosis’

Pain

M/c cause of secondary dysmenorrhea.

Subfertility

~1/4
by obstructing oocyte release or sperm entry

Endocrinologic abnormalities

Extrapelvic endometriosis

?? ?? extrapelvic site: rectum

Clinical examination

Pain
- Dyspareunia
- Dysmenorrhea
  - Endometriosis > adenomyosis
- Chronic pelvic pain
Infertility
- Endometriosis: 75% (cf. adenomyosis: 20%)
Dyschezia
Physical exam
- Mostly normal.
- Immobile uterus
- Cervical motion tenderness
- Adnexal mass
- Rectovaginal septum, posterior cul-de-sac, uterosacral ligament. nodules.

Imaging

Ultrasound

Asymmetric myometrial wall thickening with sonolucent islands in the myometrium

Other imaging

CT
- Cannot delineate endometrial implants from other soft tissue.
MRI
- Asymmetric myometrial wall thickening with bleeding spots (high intensity spots)

Imaging to assess intestinal and urologic involvement

Blood and other tests

CA125

Other tests

Laparoscopy

General considerations

Laparoscopic technique

Laparoscopic findings

Histologic confirmation

Endometrial biopsy when patients have abnormal bleeding.

Laparoscopic classification

Stage	Progression	Tissue description
I	Minimal	Presentation of 2-3 superficial implants
II	Mild	Appearance of more implants that occur within deeper layers of tissue
III	Moderate	Many deep implants in combination with minor/small endometriomas on one or both ovaries. May also present filmy adhesions.
IV	Severe	Persistance of deep implants, enlargement of endometriomas on one or both ovaries, development of dense adhesions.

Spontaneous evolution

Management

Prevention

Principles of treatment

Asymptomatic
- Require reassurance and observation only.
Endometriosis
- Conservative
Adenomyosis: hysterectomy
Pseudomenopause ?? – ?? ? ?? ??? ???
- Progestin (TOC)
- OC
- Danazol
  - 17-isoxasol-testosterone
  - S/E: ?? ??, Fluid retention, ???, ???. Fertility? ???? ???? ??? ?.
- GnRH
- Pseudomenopause? ???? ???(E+P)??.

Treatment of endometriosis-associated pain

Mild to moderate pain
- NSAIDs to decrease inflammation
Severe symptoms
- Progestin (TOC)
  - Pain? ????? ??????? ??. Hypoestrogenic state ???? ??.
- OCS
  - To suppress ovulation and reduce menstruation
  - 6~12??? continuous?? ????.
- GnRH agonist
  - S/E: vasomotor symptom, ? ?? (???: add-back or draw-back)

Ovarian endometriosis

Deeply infiltrating rectovaginal and rectosigmoid endometriosis

Surgical treatment of pain

Laparoscopic cystectomy
- ?? ??? ??/?? ??
- ?? ???, ?? 4cm ????. 4cm ???? ??

Oophorectomy and hysterectomy

Medical treatment

Oral contraceptives

Continuous contraceptives

Nonhormonal medical therapy

Treatment of endometriosis-associated subfertility

Surgical treatment

Perioperative medical treatment

~~?? ? danazol, progestin, GnRH~~ – rarely indicated, and prevents pregnancy

Highest spontaneous pregnancy rates occur during the first 6-12months after conservative surgery