sneak peek 2 handbook family medicine volume 3

                               ENDOMETRIOSIS

Gauri Utturkar

Endometriosis is defined as the presence of normal endometrial tissue implanted abnormally in location other than the uterine cavity. This tissue is composed of endometrial gland surrounded by endometrial stroma.

Signs and symptoms

About one third of women with endometriosis remain asymptomatic. Common symptoms are

• Dysmenorrhea
• Heavy or irregular bleeding
• Pelvic pain/ tenderness
• Lower abdominal or back pain
• Dyspareunia
• Dyschezia (pain on defecation) - Often with cycles of diarrhea and constipation
• Bloating, nausea and vomiting
• Inguinal pain
• Pain on micturition
• Pain during exercise
• Infertility

Diagnosis

Laparoscopy

The following sites are the most commonly involved

• Ovaries
• Posterior cul-de-sac
• Broad ligament
• Uterosacral ligament
• Rectosigmoid colon
• Bladder
• Distal ureter

Histology

Combination of endometrial glands and stroma in biopsy specimens obtained from sites outside the uterine cavity.

CA-125 assay

Usually raised more than 35 U/ml.Not of diagnostic value but useful for follow up post treatment.

Complete blood count (CBC)

Cervical Gram stain and culture,urinalysis and urine culture if indicated

Ultrasonography

Endometriosis can be assessed by either transvaginal or endorectal ultrasonography

Magnetic resonance imaging (MRI) if needed.

Management

Asymptomatic minimal endometriosis may be observed over 6-8 months. All symptomatic cases need active treatment.

Hormonal therapy

Combination oral contraceptive pills (COCPs) 

Act by ovarian suppression and continuous progestin administration. Initially a regimen of continuous or cyclic COCPs should be administered for 3 months. This treatment is continued for 6-12 months.

Progestational agents as Medroxyprogesterone, Norethindrone-act by decidualization and atrophy of the endometrium.

Gonadotropin-releasing hormone analogues as Goserelin, Leuprolide- produce hypogonadotrophic state by down regulation of the pituitary gland and cause endometriotic tissue atrophy.Danazol work by suppression of both the hypothalamic & ovarian axis by inhibiting the midcycle follicle-stimulating hormone (FSH) and luteinizing hormone (LH) surge,preventing steroidogenesis in the corpus luteum. Not preferred now as it has a higher incidence of adverse effects.

Aromatase Inhibitors Letrozole work by blocking the aromatase activity in extraovarian sites that suppress the conversion of androstenedione and testosterone to estrogen. This results in suppression of endometriosis at a local level.

Minimally invasive surgery

Primarily for management in young women.

Done through laparoscopy, destruction of endometriotic implants by diathermy.

Cauterization or laser. Excision of cysts (chocolate cysts) can be done.

Surgical therapy

Conservative surgery

The aim is to destroy visible endometriotic implants and lyse peritubal and periovarian adhesions that cause the symptom of pain. The laparoscopic approach is the method of choice for treating endometriosis conservatively.

Semiconservative Surgery

It is preferred in women who have completed their family are too young to undergo surgical menopause or but have severe symptoms.This involve hysterectomy and cytoreduction of pelvic endometriosis.

Radical surgery

Radical surgery involve total hysterectomy with bilateral oophorectomy (TAH-BSO) and cytoreduction of visible endometriosis. Adhesiolysis is performed to restore mobility and normal intrapelvic anatomy.

Pain management can include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic analgesics.

Complications

• Infertility/subfertility
• Chronic pelvic pain and subsequent disability
• Anatomic disruption of involved organ systems (e.g. adhesions, ruptured cyst)

Further reading

D.C.Dutta, Hiralal Konar,Textbook of gynaecology,5th edition,2004,New Central Book Agency(P) Ltd.,Kolkata.