Endometriosis may be defined as the presence of
functioning endometrial tissue outside the uterus. It is usually
confined to the pelvis in the region of the ovaries, uterosacral
ligaments, cul-de-sac, and uterovesical peritoneum. The development
and extension of endometrial tissue into the myometrium is termed
adenomyosis. An endometrioma may be defined as an area of
endometriosis, usually in the ovary, that has enlarged sufficiently
to be classified as a tumor. When an endometrioma is filled with old
blood, resembling tar or chocolate syrup, it is commonly known as a
Clinical features & diagnosis
Endometriosis classically presents with pelvic
pain,dyspareunia,congestive dysmenorrhoea or as infertility. Pain,is usually bilateral,
varies from mild to severe discomfort in the lower abdomen and is
often associated with rectal pressure. Many affected women complain
of lower back and leg pain. A constant soreness in the lower abdomen
or pelvis throughout the cycle, which is aggravated just before the
menses or during coitus, may be the only complaint. Since many of
these symptoms mimic many other illnesses, diagnosing endometriosis
can be difficult. Endometriosis can manifest as nodularity in the
pouch of Douglas, decreased mobility of uterus due to pelvic
adhesions, masses in the pelvis due to ovarian
best time to examine a patient with suspected endometriosis is
postmenstrually. At this time the nodularities found on pelvic
examination increase in size, confirming the suspicion of
.Besides the usual sites like ovaries, uterosacral
ligaments, cul-de-sac and uterovesical peritoneum, endometriosis can
present at unusual sites like lungs, liver, rectovaginal septum,
scar tissue, etc. These implants could present as haemoptyis
(lungs), cyclic right subcostal pain (liver), painful defaecation or
bleeding per rectum during periods (rectovaginal septum), or as pain
with defaecation and malena(Colon).
confirmatory diagnosis,currently, the "gold standard" is direct visualization of
endometrial lesions using laparoscopy, often with confirmation by
biopsy of excised endometriotic tissue.(8).Ultrasound
scanning ,a diagnostic modality used widely for the detection of a
wide arrayof pathologies is not very much useful in confirming the
diagnosis of endometriosis.
Ovarian endometriomas can be detected on ultrasound scanning,
but external endometriotic implants, for example,the ones on
uterosacrals and pelvic peritoneum cannot be picked up on
sonography. Presumptive diagnosis of adhesions can be made from the
fixity of ovaries, and uterus on ultrasound, but a definitive
diagnosis requires a laparoscope. CT scanning and MRI may be useful
in diagnosing endometriosis at extrapelvic sites of endometriosis
like lungs and liver, but are not of much use in pelvic
Medical treatment of endometriosis: The
medical therapy of endometriosis is done with agents like OC-pills,
progestins,NSAID’s,Danazol and GnRh analogues. The objective is to produce
a state of amenorrhoea which may be akin to a
pseudopregnancy(OC-Pills,progestins) or pseudomenopause(Danazol,GnRh
analogues). This inhibits or delays progression of the
OC-pills: Initial management in a patient
suspected of having endometriosis and not desiring pregnancy is to
start on OC-pills and NSAID’s for 3 months. If there is no
response, there is no
point in switching over to another brand of OC-pills or NSAID. A
more aggressive approach is needed.
Progestins: Oral administration of
medroxyprogesterone acetate, 50 mg daily,can improve symptoms in 80% of
patients with moderate to severe endometriosis. Minor bleeding,
weight gain and edema, are some of the side effects that are
usually well tolerated.
Subjective improvement in symptoms has been noted by some workers
with 30 mg of medroxyprogesterone acetate. Unfortunately, recurrence
rates have been reported to reach 42% after 2 years of therapy. As
an alternative to medroxyprogesterone acetate, one may choose to
administer norethindrone acetate, 5 mg daily for 6 months. A similar
response can also be achieved with 40 mg of megestrol acetate daily.
Parenteral medroxyprogesterone acetate depot may also be given at a
dose of 100 mg every 2 weeks for 3 months followed by 200 mg monthly
for 3 to 6 months.
Danazol: Danazol is a weakly androgenic
preparation. In doses of 200mg/day it can reduce pelvic pain but for
effectively reducing endometriosis doses that can produce
amenorrhoea is required. 400-800mg/day may be needed to produce
amenorrhoea. Danazol is
teratogenic and patients at risk of getting pregnant should be asked
to use contraception. It may be given for 8-12 weeks preoperatively
before repeat surgery. For patients who refuse surgery, 52-78weeks
course may be necessary. More than 75% of patients receiving danazol
have one or more side effects. Major side effects seen with danazol
therapy are weight
gain, edema, decreased breast size, acne, oily skin,
hirsutism,deepening of the voice, headache, hot flashes, changes in
libido, and muscle cramps.Significant weight gain (2 to 10 kg) is
not uncommon. All these side effects are reversible with the
exception of voice changes. The time course for the resolution of
androgenic symptoms may be long; 6 months or more is usual.
Agonist Therapy: GnRH is a hypothalamic
decapeptide that stimulates pituitary LH and FSH secretion.
Chemicals similar in structure to the native gonadotropin releasing
hormone is used to induce amenorrhoea. Depot preparations of these
compounds are usually used to produce amenorrhoea. The effects are
comparable to Danazol without the androgenic side effects of
Danazol. Dose: Goserlin
and leuprolide are 2 depot preparations available in India. The
dosage of leuprolide is a single monthly 3.75-mg depot injection
given intramuscularly every month. Gosarelin, in a dosage of 3.6 mg,
is administered subcutaneously every 28 days. Treatment should be
continued for at least 3months. Each injection may cost upto
Rs.7000-8000. There may be estrogenic side effects like dry vagina,
hot flashes,etc. These can be prevented by giving estrogens and
progestogens .For e.g:Conjugated estrogens in the dose of 1.25mg
with Medroxyprogesterone acetate 2.5 mg daily.
treatment of endometriosis:
Laparoscopic adhesiolysis, and fulgration of
implants form the main stay of surgical treatment. Endometriomas are drained
and the cyst lining
either peeled off
or fulgrated using cautery or laser.In women who have
completed their family hysterectomy with salpingo-oophorectomy is the definitive mode of
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