Endometriosis is a common condition in which small pieces of the uterus lining (the endometrium) are found outside the uterus. This could be in the fallopian tubes, ovaries, bladder, bowel, vagina or rectum, sigmoid colon, intestinal coils, or appendix.
Causes
- Implantation theory—Sampson’s attributed endometriosis to reflux of menstrual endometrium through the fallopian tube and its subsequent implantation and growth on the pelvic peritoneum and the surrounding structures
- Coelomic metaplasia theory—Meyer and Ivanoff stressed endometriosis arises as a result of metaplastic changes in embryonic cells
- Metastatic theory—Halban suggested that embolization of menstrual fragments through vascular or lymphatic channels occurs and this leads to the launching of endometriosis at distal sites
- Histogenesis by induction
- Hormonal influence—Development of endometriosis depends mainly on oestrogen. Pregnancy causes atrophy of endometriosis through high progesterone. Regression also follows oophorectomy and irradiation
Classification
Mild
- Scattered fresh superficial lesions.
- No scarring or retraction.
- No adnexal adhesions.
Moderate
- Ovaries are involved, with some scarring and retraction.
- Endometriomas of size less than 2 cm.
- Minimal peritubular and peri-ovarian adhesions.
Severe
- Ovaries are involved
- Endometriomas of size more than 2 cm
- Dense peritubular and peri-ovarian adhesions
- Uterosacral ligaments are thickened and involved
- Bowel and urinary tract may be involved
Symptoms and signs of Endometriosis
- Secondary dysmenorrhoea
Pain start before the onset of menstruation builds up continuously until the flow begins, and declines thereafter. Pain can be of any type (dull ache, grinding, crushing, colicky, bearing down) and backache. Radiating pain along the sciatic nerve. Pain is chiefly related to the location of the extent.
- Lower Abdominal pain.
Usually around menstruation. Occasionally the pain may become very severe.
- Dyspareunia
- Infertility is due to interference with tubal motility and function. It may inhibit ovulation.
- Menstrual symptoms like menorrhagia, irregular bleeding, polymenorrhoea
- Urological symptoms like dysuria, frequency, renal infection, hydronephrosis
- Bowel symptoms like melaena, diarrhoea, painful defaecation
- Fixed, tender, cystic swelling p/a
- Tender bluish/blackish puckered spots p/v
- Cobblestone feel of uterosacral ligaments
- Fixed, tender, cystic, bilateral mass in the pelvis
- Retroverted uterus
Investigations
- Blood tests — TLC, DLC, ESR
- Ultrasonography
- Laparoscopy
- Laparotomy
- Sigmoidoscopy
Treatment
Drug treatment
- Intermittent or regular use of oral contraceptives
- Oral progesterones
- Danazol(derivative of testosterone),Testosterone
- Gonadotropic releasing hormone(GnRH)
Surgical
- Conservative surgery
Laser/Diathermic cauterization of lesions at laparoscopy or at laparotomy
- Radical surgery is the removal of the uterus with bilateral salpingo-oophorectomy. Occasionally surgery on the bowel, bladder or ureter may become necessary.
- Radiation is indicated only in patients who are unfit for surgery and are not responding to medical treatment
Prevention
- Low-dose oral contraceptives recommended
- Tubal patency test avoided at the time of menstruation and just before the commencement of menstruation
- Genital tract operations to be done in the post-menstrual period
- Classical caesarean section/hysterotomy must be avoided