Endometriosis: An Update

Endometriosis: An Update
Mohamed Kandeel, M.D.
Professor of Obstetrics and Gynecology
Menofyia University
Egypt

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Definition and Prevalence
Endometriosis is the presence of endometrial-like tissue outside the uterus
in women of reproductive age from all ethnic & social groups. This
endometrial tissue may be found in the ovaries, peritoneum, uterosacral
ligaments and Douglas pouch. Ectopic endometrium in the uterine muscles
is known as adenomyosis. Extra-pelvic endometrial tissues; e.g. on
diaphragm, umbilicus are rarely found.
Endometriosis is present in 10% of the general population. It reaches 21%
in infertile women and 82% in women with chronic pelvic pain.

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Predisposing Factors
1-Hyperestrogenism. e.g. in cases of fibroids, metropathia, estrogen producing
tumors.
2-Cervical stenosis
3-Curettage

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Theories of etiology
1-The retrograde reflux of menstrual tissue from the fallopian tubes during
menstruation.
2-The celomic metaplasia theory. Mesothelium covering the ovaries
invaginates into the ovaries, then undergoes metaplasia into endometrial
tissue.
3-The embryonic rests theory. The müllerian remnants in the recto-vaginal
region differentiate into endometrial tissue.
The risk of endometriosis is directly proportional to the duration of
exposure to menstruation. i.e., early menarche, shorter cycle length, longer
duration of flow, or reduced parity. The risk decreases for personal habits
that may relate to decreased estrogen levels i.e., smoking, exercise.

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Endometriosis and Irradiation
In the 1970s, a group of Rhesus monkeys was exposed to various types of
irradiation with very high doses. The risk of developing endometriosis
significantly increased in the irradiated animals. Therefore; it is assumed
that women receiving whole-body or abdominal exposure to high doses of
X-rays should be considered to be at higher risk of developing
endometriosis than the unexposed. The explanation for this effect may be
through interference with normal immune system function.

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Gross-Macroscopic-Picture
1-Adenomyosis: characterized by:
-The uterus is symmetrically or asymmetrically enlarged, firm with
hyperplastic endometrium.
-Presence of multiple dark spots on uterine serosa
-Cystic spaces filled with altered blood throughout the uterine wall
-Whorled appearance with no capsule (D.D. fibroid)
2-Ovarian endometriosis: both ovaries are usually enlarged. The typical
lesion is chocolate cyst 5-6 Cm filled with altered blood. There is
thickening of tunica albuginea and ovaries are surrounded by adhesions.

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Gross-Macroscopic-Picture
3-Pelvic endometriosis: This is characterized by multiple colored nodules seen
on the uterosacral ligaments and filling the Douglas pouch. They are often
surrounded by adhesions leading to fixed retroversion of the uterus.

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Microscopic Picture
1-The finding of ectopic endometrial glands and stroma is the corner stone
to establish a diagnosis of endometriosis. It is present in 50-70% of cases.
2-Most histopathologists consider fibrosis, chronic inflammation, and/or
hemosiderin-laden macrophage highly suggestive of endometriosis.

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Diagnosis
I-Symptoms: A large percentage of women affected with endometriosis are
asymptomatic. Pelvic pain and infertility are the commonest presentation.
1-Dysmenorrhoea, deep dyspareunia, dyschezia or dysuria
2-Chronic pelvic pain
3-Ovulation pain
4-Cyclical or perimenstrual symptoms (e.g. bowel or bladder) associated with
or without abnormal bleeding. E.g. cyclic heamturia or bleeding per rectum
5-Infertility/subfertility (due to adhesions preventing ovum release or pickup,
diminished ovarian reserve with low oocyte and embryo quality).
6-Chronic fatigue

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Diagnosis (Cont.)
II-Signs: Pelvic examination reveals:
1-Pelvic tenderness
2-Fixed retroverted uterus
3-Tender utero-sacral ligaments. This sign has the highest positive likelihood
ratio.
4-Enlarged ovaries on examination is suggestive of endometriosis.
The diagnosis is more certain if deeply infiltrating nodules are found on the
utero-sacral ligaments or in the pouch of Douglas and/or visible lesions are
seen in the vagina or on the cervix.

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