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APGO educational topic number 38
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endometriosis endometriosis is a
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significant health problem that is
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estimated to affect seven to ten percent
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of women of reproductive age it has a
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prevalence of 38 percent in infertile
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women and 71 to 87 percent of women with
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chronic pelvic pain have endometriosis
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endometriosis is defined as the presence
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of endometrial glands and stroma in any
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site outside of the uterus the
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objectives of this video are to describe
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the theories of pathogenesis of
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endometriosis list the most common sites
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of endometriosis describe the symptoms
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and physical exam findings in a patient
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with endometriosis and lastly describe
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the diagnosis and management options for
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endometriosis the pathogenesis of
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endometriosis is complex and there are
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three theories on how endometrial glands
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and Stroman develop an extra uterine
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sites the first theory is retrograde
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flow here is a photograph of the uterus
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with endometrial glands and stroma in
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the endometrial cavity during
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menstruation all women have some degree
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of retrograde menstruation in women with
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endometriosis this retrograde flow
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results in endometrial glands and
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planting and pelvic sites such as the
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pelvic peritoneum posterior cul-de-sac
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and ovaries the second theory is
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vascular and lymphatic dissemination in
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this theory endometriosis cells traveled
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through the vascular and lymphatic
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system to distant sites such as the
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kidneys and pleural cavities the third
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theory is Salome Achmed aplasia in this
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theory multi potential cells in the
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peritoneal cavity develop into
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functional and a material tissue this
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theory explains the development of
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endometriosis in adolescence before the
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onset of menstruation the endometrial
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lesions can cause an inflammatory
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reaction that can lead to formation of
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significant adhesions and scarring this
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operative photograph shows a pelvis that
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had significant scarring and adhesions
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from endometriosis here is the uterus
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the left round ligament and scar tissue
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that you can see clearly distorts a
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great deal of the anatomy endometriosis
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is most commonly found in the ovaries
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and is typically bilateral this
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operative photograph shows a uterus and
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bilateral endometrium us with the
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characteristic brown hemosiderin
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and fluid other common sights include
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the posterior cul-de-sac in particular
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the uterus sacral ligaments and rector
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vaginal septum the round ligament the
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fallopian tubes and the sigmoid colon
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more rarely endometriosis can be found
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in abdominal surgical scars the
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umbilicus and more distant sites such as
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the brain lungs and upper ureters
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intraoperatively endometriosis can
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visually look like clear white lesions
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like brown powder burn lesions or dark
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red or blue domes it is important to
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note that women with endometriosis
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demonstrate a wide variety of symptoms
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some women with extensive endometriosis
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have minimal symptoms and conversely
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women with minimal endometriosis may
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have severe symptoms the classic –
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symptoms of endometriosis are
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dysmenorrhea or painful menses and
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dyspareunia or painful intercourse
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infertility is more frequent in women
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with endometriosis the relationship
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between infertility and endometriosis is
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complicated and a direct
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cause-and-effect relationship has not
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been clearly established the infertility
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may be secondary to pelvic scarring and
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adhesions that distort the pelvic
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Anatomy prostaglandins and Auto
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antibodies have also been implicated
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endometriosis is present in 30 to 50
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percent of asymptomatic infertility
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patients less common symptoms of
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endometriosis include disc easia or
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painful bowel movements and hematochezia
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rectal bleeding let’s move now to
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physical exam it is common to not find
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any signs of endometriosis on physical
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examination since the endometrial
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implants are usually very small and not
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palpable the possible findings include a
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fixed non-mobile uterus that is
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retroflex secondary to adhesions or
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ovarian endometrium Azure chocolates
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Ismaili tender and palpable and the
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classic sign on physical examination is
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uterus sacral nodularity although
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endometriosis can be suspected in women
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with the symptoms and exam findings
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described thus far the diagnosis of
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endometriosis is made in the operating
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room
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this can be by direct visualization of
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tissue and confirmed with tissue biopsy
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the pathologist will look for two or
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more of the following histological
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features in the biopsy endometrial
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epithelium and Demetrio glands
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endometrial stroma
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and our hemosiderin Laden macrophages
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the goals of management are one
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reduction of pelvic pain to minimize
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surgical intervention as much as
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possible and three preserve fertility
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medical therapy the goal is to induce
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atrophy of the endometrial glands and
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stroma of endometriosis oral
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contraception as first-line therapy for
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is easy to administer and has few side
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effects it induces a decidua reaction of
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functioning and Dimitri otic tissues
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alternatively progesterone therapy which
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can be administered either orally or
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with a diploma Drakh C progesterone
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injection or with an implant can also
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suppress gonadotropin release which
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decreases a rare and stereo Genesis
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which will suppress under meetry OSIS
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similarly a GnRH agonist down regulates
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pituitary gland and induces a menopause
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for patients side effects do thus
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include hot flashes and night sweats a
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GnRH agonist cannot be used as long-term
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therapy for young patients because of
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the detrimental effects of low estrogen
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levels Dan Issel is an additional
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medical therapy option it similarly
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suppresses LH and FSH from the pituitary
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side effects are also related to
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menopause estate including hot flashes
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and night sweats Dennis also has
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androgenic properties so women may
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experience acne oily skin growth of
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facial hair and deepening of the voice
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surgical therapy involves conservative
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therapy such as excision cauterization
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or ablation of visible endometriosis
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lesions and license of adhesions
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extirpate of therapy involves
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hysterectomy with or without a bilateral
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self-injury for ectomy this is reserved
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for women for whom conservative medical
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or surgical therapy is not feasible or
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when the patient does not desire future
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fertility this concludes the aapko video
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on endometriosis we have discussed the
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pathogenesis the most common sites of
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symptoms and physical exam findings for
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the patient with endometriosis as well
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as the diagnosis and management options
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for this disease
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[Music]