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Endometriosis : Causes, Signs and symptoms, Pathophysiology, Diagnosis and Treatment / Gynecology

Introduction

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Endometriosis is the growth of endometrial tissue outside the uterine cavity, affecting various organs except for the spleen. It primarily affects women in their reproductive age group, typically between 25 to 40 years.

What is Endometriosis

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Endometriosis is a disease affecting reproductive age women, where tissue similar to the endometrium grows outside the uterine cavity.

Why Endometriosis

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Theories of Endometriosis Endometriosis is a condition where the endometrium grows outside the uterine cavity. Samson's theory suggests retrograde menstruation as a cause, but it cannot explain distant endometriosis or its occurrence in pre-menarchal females. Other theories include benign metastatic theory and metaplastic theory, which propose different mechanisms for how endometrial tissue reaches distant organs.

Risk Factors for Endometriosis Retrograde menstruation is common in 70-80% of women, but not all develop endometriosis due to immune system phagocytosing implants. Low immune status and hyperestrogenic states are risk factors; high estrogen levels promote proliferation of endometric implants.

Single liner questions

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Understanding Endometriosis Endometriosis can occur anywhere in the body except for the spleen, with ovaries being the most common site and pouch of Douglas as the second most common. The least common site is brain, while scar endometriosis occurs on surgical scars like hysterectomy or c-section scars. Ovarian endometrioma results in a chocolate cyst that may rupture and cause brownish fluid due to hemosiderin pigment.

Diagnostic Imaging of Endometrial Cysts Transvaginal ultrasonography reveals a ground glass appearance of ovarian chocolate cysts with homogeneous internal echoes. This imaging technique helps diagnose endometrial cysts by identifying their characteristic features.

vicarious menstruation

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Vicarious menstruation refers to cyclical bleeding from unusual locations such as the eyes or nose, coinciding with normal menstrual periods. This condition occurs when endometrial implants reach distant areas like the orbits, lungs, or nose and bleed during menstruation.

risk factors

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Risk Factors for Endometriosis Endometriosis risk factors include high estrogen levels, increased number of menstrual cycles, early or late menopause, family history of endometriosis (6-10 times higher risk), low BMI, and Mullerian anomalies caused by exposure to diethylstilbestrol. Nulliparity and prolonged menstruation also increase the risk due to continuous menstrual cycles and retrograde menstruation.

Impact of Race on Endometriosis Risk Uterine fibroids are more common in black females while endometriosis is mostly seen in white females. Short lactational intervals can lead to more frequent menstrual cycles and increase the chances of retrograde menstruation causing endometriosis.

Diagnosis

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The gold standard for diagnosing endometriosis is laparoscopy, which allows direct visualization of the abdominal and pelvic cavity. Endometrial deposits can be seen during this procedure, and it also serves as a therapeutic method to excise or burn these deposits. The uterosacral ligament in close proximity to the cul-de-sac is commonly affected by endometrial deposits, leading to nodularity that can be felt during examination.

Laparoscopy

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The laparoscopy reveals enlarged ovaries with brownish-black deposits, indicating endometrial implants. The condition is diagnosed as endometrioma or chocolate cyst, characterized by inflammation and fibrosis. The presence of pseudo-xanthoma cells suggests macrophages eating up the blood pigment (hemosiderin). Endometrioma increases the risk of epithelial ovarian cancers such as clear cell carcinoma and endometrioid cancer.

Staging of endometriosis

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Endometriosis is staged as minimal, mild, moderate, and severe based on the depth and size of endometrial implants. Minimal endometriosis involves superficial implants that do not penetrate deeply into organs. Mild endometriosis features slightly deeper implants. Moderate endometriosis includes small chocolate cysts on one or both ovaries. Severe endometriosis is characterized by large chocolate cysts.

Clinical Features

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Clinical Features of Endometriosis Endometriosis causes severe pain during menses, known as secondary dysmenorrhea. It can also lead to adnexal masses, infertility, dyspareunia (pain during intercourse), and menorrhagia. The pain is caused by bleeding from endometrial implants, inflammatory cytokines acting on the peritoneal cavity, and irritation of nerve endings due to deep tissue invasion.

Pathophysiology of Pain in Endometriosis The depth of endometrial implants determines the severity of pain in endometriosis. Deeper implants cause more intense pain by irritating nerve endings. Inflammatory cytokines such as prostaglandins E2 contribute to the pain by acting on the peritoneal cavity. Additionally, bleeding from these implants leads to inflammation and further contributes to the painful symptoms.

Infertility

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Endometriosis causes infertility due to chronic inflammation, which leads to the production of inflammatory mediators that impair the function of ovaries, fallopian tubes, and endometrium. The inflammation results in scar tissue or adhesions that distort the tubo-ovarian relationships, preventing proper capture of ovum by fallopian tubes for fertilization.

Examination Findings

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The examination findings reveal a retroverted uterus, nodularity in the uterosacral ligament, and enlarged adnexa. Elevated CA125 levels indicate non-neoplastic conditions such as endometriosis or benign tumors.

Management

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The aim of managing endometriosis is to decrease estrogen levels, induce endometrial atrophy, and create a state of amenorrhea. This prevents the growth and shedding of endometrial tissue outside the uterus, reducing pain for the patient.

Drugs

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Treatment for Mild Pain in Endometriosis For mild pain in endometriosis, non-hormonal drugs like NSAIDs can be used. If the patient also has menstrual complaints and infertility, oral contraceptive pills (OCPs) are the drug of choice.

Severe Endometriosis Treatment In cases of severe uncontrollable pain, treatment involves starting with GnRH analogs directly to manage the symptoms effectively.

Oral Contraception

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Oral Contraceptives in Endometriosis Oral contraceptives (OCPs) containing estrogen and progesterone downregulate follicle stimulating hormone, leading to decreased estrogen levels. Continuous use of OCPs for three months creates a state of amenorrhea, preventing ovulation and reducing pain associated with endometriosis.

Aromatase Inhibitor in Endometriosis Treatment Aromatase inhibitors like letrozole inhibit the conversion of androgens to estrogens by blocking the enzyme aromatase. This leads to reduced estrogen levels, which is beneficial in treating endometriosis.

Progesterone

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Progesterone acts as an aromatase inhibitor, reducing peripheral conversion and estrogen levels. This is important in managing endometriosis by preventing endometrial proliferation caused by a hyperestrogenic state.

GNH Analogues

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Progesterone Drugs The progesterone drug DMPA (Dipo Metroxy Progesterone Acetate) stabilizes the uterine endometrium and other areas of the body. It is given in a 550 milligram dose every three months to cause this stabilization.

GnRH Analogues Continuous administration of GnRH analogs desensitizes receptors on gonadotropes, leading to decreased estrogen levels. Prolonged use may lead to osteoporosis due to reduced inhibition of osteoclast-mediated bone destruction by estrogens, requiring an add-back regime with low-dose estrogens or selective estrogen receptor modulators like raloxifene.

Surgical Management

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Surgical Management of Endometriosis Surgical management of endometriosis involves laparoscopy for diagnosis and treatment. Endometrial deposits can be removed through cystectomy, ablation, or adhesiolysis to relieve pain and restore fertility. Ablation of sensory nerves can also alleviate pain.

Management of Infertility Infertility in mild endometriosis is treated with ovulation-inducing drugs like clomiphene citrate followed by intrauterine insemination. Severe endometriosis may require in vitro fertilization directly to overcome infertility.