Defining the disease * Chronic disease marked by presence of endometrial tissue (glands and stroma)outside of endometrial cavity * Can be located anywhere in body * Common places in decreasing order: 1. Ovaries, Anterior/Posterior cul-de-sac, Posterior Broad ligament, Uteroscacral ligament, Fallopian tubes, Sigmoid colon + MORE
Three Theories of pathogenesis 1. Halban Theory – Transport via lymphatic system 2. Meyer Theory – multi-potential cells in peritoneum undergo metaplastic transformation 3. Sampson Theory – Retrograde menstruation via fallopian tubes 4. Altered Immunity – deficiency in cellular immunity or NK cells result in inability to recognize the presence of endometrial tissue
Epidemiology
1. Prevalence between 10-15%; true Prevalence is unknown – need surgical confirmation for diagnosis 2. Age group : found almost exclusively in age of reproductive women 3. Single most common reasons for hospitalization of women in this age group 4. Suspected in 20% chronic pelvic pain and 30-40% of infertility
Clinical Manifestations 1. Timing 1. Begins: Cyclic Pelvic pain begins 1 or 2 weeks before menses 2. PEAKS: 1-2 days before onset of menses 3. Subsides: at onset of menses or shortly there after 2. Classic symptoms: Dysmenorrhea, Pelvic Pain, Dyspareunia, infertility 3. Severity of pain does not reflect extent of disease
Perform exam during early menses; implants are more likely to be largest and most tender 1. Subtle or nonexistent in early stages of disease 2. Later stages: Think scaring and fibrosis: Uterosacral nodularity , fixed retroverted uterus, tender fixed adnexal mass
Diagnosis - Imaging 1. First line imaging - suspected endometriosis have pelvic ultrasounds 2. ONLY Definitive way to diagnosis endometriosis is through direct visualization with laparoscopy “: rust colored”, “powder burns”, “blue colored mulberry lesions”, “chocolate cyst” in ovaries
Treatment
1. Expectant management: for minimal symptoms 2. Analgesia 3. Hormonal medical therapy –CI in pts attempting to conceive 1. Estrogen-progestin oral contraceptives 2. Cyclic or continuous Gonadotropin-releasing hormone (GnRH) agonists -Lupron 3. Progestins, given by an oral, parenteral, or intrauterine route 4. Danazol –androgen derivative 5. Aromatase inhibitors (Anastrazole) – off label for severe 4. Surgical intervention 6. Conservative: retain uterus and ovarian tissue; excise visible implants 7. Definitive: Total hysterectomy and bilateral salpingo-oopherctomy, lysis of adhesions, and removal of visible lesions 5. Combination therapy in which medical therapy is given before and/or after surgery