Download - ENDOMETRIOSIS. Endometriosis definition The presence of endometrial tissue in extrauterine locations
ENDOMETRIOSIS
Endometriosis definition
The presence of endometrial tissue in extrauterine locations .
Endometriosis - pathogenesis
The exact pathogenesis is unknown
Three major theories:
1. Theory of the implantation (Sampson´s theory) – direct implantation of endometrial cells, typically by means of retrograde menstruation.
Endometriosispathogenesis
2. Coelomic metaplasia of multipotential cells in the peritoneal cavity (Meyers theory) states that, under certain conditions m-p cells can develop into endometrial tissue
3. Vascular and lymphatic dissemination of endometrial cells (Halbans theory) – distant sites of endometriosis can be explained by this process ( lymph nodes, pleura, kidney)
• Adenomyosis
(endometrial tissue in uterine wall)
• Adenomyoma
(endometrial tissue in uterine myomas)
• Endometriosis in the wall of uterine tube
Endometriosis division by Semm
Internal endometriosis of genital organs
Endometriosis division by Semm
External endometriosis of genital organs:
• Ovary: - endometrioma
(the endometrial tissue deeply in ovary tissue as a tumor)- on the surface of ovary.
• Uterosacral ligaments, round ligament of the uterus.• Uterine tubes
Endometriosis division by Semm
External endometriosis of genital organs:
• Anterior et posterior cul-de-sacs
• Pelvic peritoneum over uterus
• Uterine cervix
• Fornix of the vagina, vagina
• Perineum
Endometriosis division by Semm
Extragenital endometriosis
• Sigmoid colon, ampula of the rectum, cecum, appendix
• Urinary bladder• Umbilicus• Postoperative scars
(laparotomia, cesarean section)
Endometriosis division by Semm
Extragenital endometriosis
• Omentum• Small intestine• Femoral canal• Arms, legs• Lungs, pleura• Brain• Kidney
Endometriosis the most common sites
• Surface of the ovary – 60 – 70%• Endomerioma (ovary) – 30-40%• Peritoneum over the uterus – 40-50%• Uterine tube and mesosalpinx – 20 – 30%• Posterior cul–de–sac - 20- 30%• Uterosacral ligaments - 20-25%• Rectosigmoid - 7-10%
Endometriosis symptoms
• Pelvic pain• Dysmenorrhea• Dyspaurenia• Dysuria, hematuria• Dyschesia, rectal bleeding• Abnormal bleeding
(irregular menstrual periods, premenstrual spotting)
Endometriosis complications
• Infertility
• Abortions
• Acute abdominal emergency (rupture or torsion of an endometrioma)
Infertility
• In the group of infertile women the endometriosis occurs in 30-50%
• In the group of women with the endometriosis infertility occurs in 30-70%
The higher stage of endometriosis –
the lower chance of pregnancy.
Infertilityreasons
• Distortion of the elements of the reproductive tract and damage to the ovary (obstruction of the uterine tube, adhesions, cysts)
• Functional infertility (the influence of prostaglandin, IL-5, IL-6, complement: C3,C4 macrophages, LT helper, LT supresors, NK - anovulation, luteal phase inadequacy, phagocytosis of sperm, oocytes, unproper conditions to the implantation
Endometriosis the risk factors
• Congenital anomalies that promote retrograde menstruation
• Short period, long lasting menstruation
• Dysmenorrhea
• Infertility
• First and second degree relatives have had endometriosis
Endometriosis diagnosis
• Anamnesis • Physical examination• Laboratory studies are not useful at making
the diagnosis but helpful in the differential diagnosis
• Pelvic ultrasound• Laparoscopy• Histopathological examination
Endometriosis diagnosis
• Establishing a diagnosis requires direct visualisation at the time of the diagnostic laparoscopy or the laparotomy
• Histopatological confirmation of endometriosis is „the gold standard”
Laparoscopy / Laparotomydescription of the lesions
• Peritoneum: vascular hemorrhagic areas, white - opaque plaques, spots described as „mulberry” or „raspberry”, fibrosis surrounding these lesions, adhesions
• Ovary : endometriomas – filled with thick, chockolate-appearing fluid; superficial implants
• Uterine tubes: tubal occlusion, adhesions, distortion
• Uterus: superficial implants, retroverted and fixed
Endometriosisstaging
Classification system by the AFS • Stage I – minimal 1-5• Stage II – mild 6-15• Stage III – moderate 16-40• Stage IV – severe >40• Evaluation of areas of endometriosis
(size,localization); adhesions (types, localization), posterior cul-desac obliteration, tubal occlusion
Endometriosis differential diagnosis
• Abdominal pain ( PID, GI dysfunction, adhesions, tumors)
• Dysmenorrhea• Dyspaurenia
(PID, colpitis, uterine retroversion)
• Abnormal bleeding
(hormonal dissfunction, polyps, cervical lesions)
Endometriosis differential diagnosis
• Acute abdominal emergency (ectopic pregnancy, adnexal torsion,
rupture of corpus luteum, acute PID – peritonitis)
• Dysuria, dyschesia, hematuria, rectal beeding, hemoptysis, tumor in the scar - rare symptoms
Endometriosistreatment
The choice of therapy depends on
• Presenting symptoms and their severity
• Location and severity of endometriosis
• Desire for future childbearing
Endometriosistreatment
3 stages of the treatment by Semm• I stage: laparoscopy - surgical tratment:
electrocoagulation of endometriosis, removal of the cysts and adhesions
• II stage: medical therapy 3 – 6 months
• III stage: surgical therapy – removal of remaining endometriosis, salpingoplasty
Endometriosismedical therapy
3 groups of medicines:1. Danazol
2. Progestins
3. Gonadotropin-releasing hormone agonists
Progestinsendometriosis treatment
• Medroxyprogesterone acetate
Provera tb 20 – 40 mg/d
• Depomedroxyprogesterone acetate
Depo-Provera inj. i.m. 100 mg / 2 weeks – 8 weeks,
than 200 mg/1 month
Progestinsendometriosis treatment
Progestins supress FSH/LH release and ovarian steroidogenesis
„a state of pseodopregnancy”
Progestins endometriosis treatment
• Adverse effects: nervous system - depresion, headache, vertigo, nervosity;
skin - oily skin, itch, hirsutism;
mastalgia, nausea, weight gain;
thrombosis, alterations of lipoprotein, glucose and Ca and P metabolism
Danazol endometriosis treatment
• Danazol-17α-ethinyl testosterone derivative
tb 600 - 800 mg/d – 1 month, than 400 mg up to 6 months
• Supresses FSH/LH release and steroidogenesis endometrial atrophy
„a state of pseudomenopause”
Danazol endometriosis treatment
• Adverse effects: hypoestrogenic and androgenic properties: acne , oily skin, hirsutism, spotting, bleeding, hot flushes, atrophic vaginitis nausea, depresion, nervosity, headache, vomit, alterations of lipoprotein, glucose, Ca and P metabolism
GnRh agonists endometriosis treatment
• Triptorelin –
Decapeptyl depot a 3.75 mg inj i.m. 1x/28d,
Dipherelinum SR a 3.75 mg inj i.m. 1x/28d
• Goserelin –
Zoladex a 3.6 mg inj s.c 1x/28d
Therapy 3 – 6 months
GnRh agonists endometriosis treatment
• Pituitary desensybilisation supress FSH/LH release
„a state of pseudomenopase”
GnRh agonists endometriosis treatment
• Adverse effects:
hypoestrogenic propierties without androgenic effects
• The most expensive therapy but the most effective one