Definition • Is a condition in which tissues similar to normal endometrium in structure and function are found in sites other than the lining of the uterine cavity.
Factors influencing development of endometriosis • Familial,genetic • Race • Low S.E.C • Menstrual factors • Delayed child bearing • Out flow obstruction • Hormones • Smoking • Immunological factors
Pathogenesis • Sampson implantation theory • Coelomic metaplasia theory • Embryonic cell rests theory • Lymphatic and haematogenous dissemination • Iotrogenic dissemination
Types • Endometriosis interna • Endometriosis externa
Symptoms • Pelvic pain dysmenorrhoea,dyspareunia,low backache,lower abdominal pain. • Menstrual irregularity • Infertility • Haemoptysis,haematuria,malena
Physical Examination • Multiple tender nodules along the uterosacral ligaments and above the post fornix of vagina
Possible mechanism by which endometriosis cause infertility • Mechanical factors • Adhesions,scarring,distortion of • tubo ovarian relationship • Altered tubal motility • Alteration in peritoneal fluid and local response • Direct toxic effect • Increased phagocytosis of sperms
Cellular Secretory Products increased peritoneal fluid PGS,interleukin Alteration in systemic immune response Ovulatory dysfunction
Diagnosis • Symptoms and signs • USG • MRI • CA- 125 • laparoscopy
Prophylaxis 1. tubal patency tests not to be performed after curettage or at the time of menses 2.pelvic examination or manipulation should not be performed during menses 3.women with family HO endometriosis should complete their family as soon as possible 4. Coc pills with low oestrogen and strong progesterone should be recommended.
Treatment Depends on: • Patients age • Future fertility desire • Extent of disease • Severity of symptoms
Medical Therapy Analgesic therapy • Nonsteriodal antiinflammatory drugs • Prostaglandin synthesis inhibitory drugs
Hormonal Therapy • Pseudopregnancy by Either daily use of progesterone or combined oral contaceptive pills for Six months
Pseudomenopauseby Danazol Acts at the hypothalamic pituitary level and decrease gonadotrophin production. Directly interfere ovarian steriodogenesis Directly binds to androgenic receptors in the endometriosis and cause its atrophy Side effects • a.androgenic like acne,hirsutism,fatigue,headache. • B.of decreased estrogen levels • Hot flushes,sweating,breast atrophy. .
Lh Rh Analogue like Buserelin,Goserelin • Cause down regulation of pituitry and induce a state of hypogonadotrophic hypogonadism Side effects • Hotflushes,vaginaldryness,dyspareunia,osteoporosis
Surgical treatment • Type of surgery depends on • Age of patient • Desire for future fertility • Extent of the disease • Symptoms
Minimal endometriosis in young/infertile • Encouraged to become pregnant • Laparoscopic fulgration • Laparoscopic laser • Danazol • Gn Rh agonist
Moderate To Severe Endometriosis • Conservative surgery (CSEL) • Ancilliary operative procedures like PSN, myomectomy/ Appendectomy pre and post op hormone suppression ART e.g.. ET, IVF, GIFT Immunotherapy
Therapy after completion of family • Total abdominal hysterectomy with bilateral salpingo oophorectomy