Contents:
Definition
Risk factors
Sites of lesion
Classification
Clinical presentation
Physical examination
Investigations
Differential diagnosis
Management
Complications
Follow up
Prognosis
Definition:
Endometriosis is defined by the presence of ectopic endometrial tissues outside of the uterus. The endometrial tissues contain both glandular and stromal elements. The exact prevalence is unknown. However, it is estimated to be 6-10% in the general female population.
Risk factors:
• Women with uterine or genital tract outflow abnormalities
• Nulliparity
• Delayed child bearing
• Early menarche (first menses)
• Regular and short cycle interval of menstruation where the duration is longer and heavy menstrual flow present
• Exposure to environment toxins
• There is presentation of familial predisposition (multifactorial)
Sites of lesion:
• Ovaries and pelvic peritoneum are the commonest sites
• Utero-sacral ligaments, fallopian tubes and rectovaginal septum
• Vagina will be affected as the extension from uterosacral or rectovaginal disease or on vaginal vault during hysterectomy
• Other sites consist of urinary tract (includes ureter and bladder), bowel, intra abdominal organs, pulmonary and abdominal and episiotomy scar.
Classification:
Most common use classification is the revised American Society Reproductive Medicine Classification of Endometriosis (1996). This system scoring is based on visual inspection and is divided into 4 categories:
Stage Score Severity of disease
Stage I 1 – 5 Minimal
Stage II 6 – 15 Mild
Stage III 16 – 40 Moderate
Stage IV >40 Severe
This scoring system reflects the anatomical severity of endometriosis. The pitfall of this system is it has poor correlation between the score, the degree of symptoms and the prognosis regarding fertility of the patients.
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Contents:
Definition
Risk factors
Sites of lesion
Classification
Clinical presentation
Physical examination
Investigations
Differential diagnosis
Management
Complications
Follow up
Prognosis
Clinical presentation:
Most cases present with classic triad of dysmenorrhea, dyspareunia and infertility.
• Asymptomatic in 20-30% of women
• Infertility (30-40% of patients with endometriosis)
• Dyspareunia (painful sexual intercourse due to rectovaginal or uterosacral involvement)
• Dysmenorrhea (painful menstruation)
• Dyschezia (painful defecation)
• Chronic pelvic pain
• Intermenstrual bleeding (Per vaginal bleeding in between normal menstrual cycle)
• Premenstrual spotting
• Abdominal swelling due to endometrioma
• Spontaneous abortion (theoretic)
• Luteinized unruptured follicle syndrome
• Bowel and urinary symptoms if there is involvement of these particular organs
Findings of physical examination:
• Pelvic mass due to endometrioma
• Tenderness on bimanual examination or during rectovaginal examination (particularly during menstruation
• Fixity of pelvic organs with retroverted uterus
• Tender and nodular uterosacral ligaments
Investigations:
• No particular laboratory test is useful to reach for diagnosis
• Cancer antigen 125 (CA 125) may be elevated –it is often done to rule out epithelial ovarian malignancy. The level is usually mildly elevated in severe disease.
• Vaginal/abdominal ultrasound – may be seen in endometriomas of ovaries
• MRI (Magnetic Resonance Imaging) – highly accurate to look for pelvic masses (endometriomas). However it has limited sensitivity in detecting diffuse endometriosis.
• Hysterosalphingography (HSG) for tubal occlusions proximally or distally and periadnexal adhesions
• Diagnostic laparoscopy (biopsy of endometriotic lesions usually demonstrates both endometrial glands and stroma.
• Colonoscopy if rectal bleeding is present
• Patients should be monitor serum estradiol levels until <10pg/ml (37pmol/L) when using GnRH analogs
• Monitor patients for pain response and size of ovarian endometriomas with ultrasound 8-12 weeks
Some differential diagnosis:
• Causes of acute abdomen (e.g.: acute appendicitis)
• Complications of intrauterine and extrauterine pregnancy (ectopic pregnancy)
• Urinary tract infection
• Irritable bowel syndrome
• Ulcerative colitis
• Crohn’s disease
• Pelvic adhesions
• Pelvic inflammatory disease (PID)
• Acute salphingitis
• Ruptured ovarian cyst
• Hemorrhagic cyst
• Hernia
• Intussusceptions
• Malignancies
• Uterine leiomyomata
• Adenomyosis
• Psychologic disorder
• Nerve entrapment syndrome
• Scoliosis
• Muscular skeletal strain
• Interstitial cystitis
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