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ENDOMETRIOSIS

 

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Definition

 

  1. the proliferation and functioning of endometrial tissue outside of the uterine cavity
  2. incidence: 15-30% of all premenopausal women
  3. mean age at presentation: 25-30 years

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Etiology

 

  • unknown

Theories

  1. retrograde menstruation theory of Sampson
  2. Mullerian metaplasia theory of Meyer
    • endometriosis results from the metaplastic transformation of peritoneal mesothelium under the influence of certain unidentified stimuli
  3. lymphatic spread theory of Halban
  4. surgical transplantation
  5. deficiency of immune surveillance

Predisposing Factors

 

  1. nulliparity
  2. age > 25 years
  3. family history
  4. obstructive anomalies of genital tract

Sites of Occurrence

 

  1. ovaries
    • most common location
    • 60% of patients have ovarian involvement
  2. broad ligament
  3. peritoneal surface of the cul-de-sac (uterosacral ligaments)
  4. rectosigmoid colon
  5. appendix

Symptoms

 

  1. there may be little correlation between the extent of disease and symptomatology
  2. pelvic pain
    • due to swelling and bleeding of ectopic endometrium
    • unilateral if due to endometrioma
  3. dysmenorrhea (secondary)
    • worsens with age
    • suprapubic and back pain often precede menstrual flow (24-48 hours) and continue throughout and after flow
  4. infertility
    • 30-40% of patients with endometriosis will be infertile
    • 15-30% of those who are infertile will have endometriosis 
  5. dyspareunia  :  on deep penetration
  6. premenstrual and postmenstrual spotting
  7. bladder symptoms :  frequency, dysuria, hematuria
  8. bowel symptoms
    • direct and indirect involvement
    • diarrhea, constipation, pain and hematochezia

Diagnosis

 

  1. truly a surgical diagnosis
  2. history  :  cyclic symptoms - pelvic pain,dysmenorrhea,dyschezia
  3. physical examination
    • tender nodularity of uterine ligaments and cul-de-sac
    • fixed retroversion of uterus
    • firm, fixed adnexal mass (endometrioma)
  4. laparoscopy
    • dark blue or brownish-black implants (mulberry spots) on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
    • chocolate cysts in the ovaries (endometrioma)
    • “powder-burn” lesions
    • early white lesions and blebs

ENDOMETRIOSIS

 

Treatment

 

Medical

  1. Pseudopregnancy
    • cyclic estrogen-progesterone (OCP) or medroxyprogesterone (Provera)
  2. Pseudomenopause
    • danazol (Danocrine) = weak androgen, s/e:  weight gain, fluid retention, acne, or hirsutism
    • Leuprolide (Lupron) = GnRH agonist (suppresses pituitary GnRH)  s/e: hot flashes, vaginal dryness, reduced libido, and osteoporosis with prolonged use
    • these can only be used short term because of osteoporotic potential

Surgical

  1. laparoscopic resection and lasering of implants
  2. lysis of adhesions
  3. use of electrocautery
  4. unilateral salpingo-oophorectomy
  5. uterine suspension
  6. rarely total pelvic clean-out
  7. +/- follow-up with 3 months of medical treatment
ENDOMETRIOSIS ENDOMETRIOSIS Reviewed by Radiology Madeeasy on August 19, 2010 Rating: 5
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