Endometriosis

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,appendix.

CAUSES—–                                           

1. Implantation theory—Sampson’s  attributed  endometriosis to reflux of menstrual endometrium through the fallopian tube and its subsequent implantation and growth on pelvic peritoneum and the surrounding structures
2. Coelomic metaplasia   theory—Meyer and Ivanoff stressed endometriosis arises as a result of metaplastic changes in embryonic cells
3. Metastatic theory—Halban suggested that embolization of menstrual frgments through vascular or lymphatic channels occur and this leads to the launching of endometriosis at distal sites
4. Histogenesis by  induction
5. Hormonal influence—Development of endometriosis depends mainly on oestrogen. Pregnancy causes atropohy of endometriosis through high progesterone.Regression also follows oophorectomy and irradiation

CLASSIFICATION—

MILD—

1. 1. Scattered fresh superficial lesions.
   2. No scarring or retraction.
   3. No adnexal adhesions.

MODERATE—

1. Ovaries are involved, with some scarring and retraction.
2. Endometriomas of size less than 2 cm.
3. Minimal peritubal and peri-ovarian adhesions.

SEVERE-

1. 1. Ovaries are involved
   2. Endometriomas of size more than 2 cm
   3. Dense peritubal and peri-ovarian adhesions
   4. Uterosacral ligaments are thickened and involved
   5. Bowel and urinary tract may be involved

Symptoms  and Signs

SYMPTOMS—

• 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 sciatic nerve. Pain is chiefly related to the location of the extent.

• Lower Abdominal pain.

Usually around menstruation. Ocassionally the pain may become very severe.

• Dyspareunia
• Infertility, due to interference with tubal motility and function.It may inhibit ovulation.
• Menstrual  symptoms

Menorrhagia , Irregular bleeding, Polymenorrhoea

• Urological symptoms

Dysuria, Frequency, Renal infection, Hydronephros

• Bowel  symptoms

Malaena, diarrhoea, Painful defaecation

SIGNS–

1. Fixed, tender ,cystic swelling p/a
2. Tender bluish/blackish puckered spots p/v
3. Cobblestone feel of utero-sacral ligaments
4. Fixed,tender,cystic,bilateral mass in pelvis
5. Retroverted uterus

INVESTIGATIONS—  

1. Blood tests—

TLC, DLC, ESR

2. Ultrasonography
3. Laparoscopy
4. Laparotomy
5. Sigmoidoscopy

TREATMENT—

• Drug treatment—

1. 1. Intermittent or regular use of oral contraceptives
   2. Oral progesterones
   3. Danazol(derivative of testosterone),Testosterone
   4. Gonadotropic releasing hormone(GnRH)

• Surgical –

1. 1. Conservative surgery

Laser/Diathermic cauterization of lesions at laparoscopy or at laparotomy

2. Radical surgery

Removal of the uterus with bilateral salpingo-oopherectomy.Occasionally surgery on the bowel, bladder or ureter may become necessary.

3. Radiation—

                 Indicated only in patients who are unfit for surgery and not responding to medical treatment

Prevention—

1. Low dose oral contraceptives recommended
2. Tubal patency test avoided at the time of menstruation and just before the commencement of menstruation
3. Genital tract operations to be done in post-menstrual period
4. Classical caesarean section/hysterotomy must be avoided