Endometriosis - MITR

Endometriosis

It is a disease process in which the tissue cells lining the uterine cavity are displaced outside
the uterus in the surrounding pelvic areas.A inflammatory response is noted in these cells in
response to reproductive hormones giving rise to various symptoms like irregularities in
menstrual cycle and bothersome pelvic pain.Sometimes endometriosis is one of the cause for
Infertility.
Endometriotic cyst also commonly known as chocolate cyst is one of the common
presentation seen in endometriosis.Not so uncommon presentation of endometriosis is seen in
bowel causing bowel obstruction and ureter,bladder giving rise to hematuria.
Diagnosis of endometriotic cyst is done by Ultrasound imaging and blood test- CA 125 .
Management-
1. Medical management has a role in treating endometriosis.medicines used are
Dinogest,GnRh ,Progestins.
2. Surgery

Minimally invasive endometriotic cyst excision.This technique is performed using general
anaesthesia..And similar to Laparoscopy technique 3-4 ports of less than 1cm are
introduced into the abdomen.1visual bed side Robotic units and 3 bedside Robotic units are
used during the surgery.Surgeon sits on a Robotic console and controls the bedside units arms
for performing the surgery with amplified vision and more precision.Endometriotic cyst is
incised and chocolate coloured cyst material is aspirated and the cyst wall is separated from
the ovarian tissue.
Sometimes there is recurrence of endometriotic cyst

Endometriosis

Definition: Endometriosis is a gynecological condition in which normal uterine cavity lining called endometrium is implanted in and around the female reproductive tract.

Epidemiology: Endometriosis is a hormone specific disease and is commonly seen in the reproductive age group. Incidence is unknown because disease diagnosis is based on biopsy or laparoscopic visualization of endometrial implants. Reports show the rate as high as 20%-50% in female partner of infertile couples. The incidence increases with age from 12% in girls aged 11-13 yrs to 45% in females aged 20-21 yrs. There are increasing reports of Endometriosis in females after menarche. In menopause the disease process halts.

Etiology and Pathophysiology is poorly understood. Retrograde menstruation, genetics, immunological dysfunction are few leading theories which attempt to explain the cause of endometriosis although none of these theories have been proven.

The common sites in which endometriosis is seen are –

Ovaries
Posterior cul-de-sac
Uterosacral ligament
Broad ligament
Rectosigmoid colon
Bladder
Ureter

Symptoms and Signs:

Clinical presentation depends on the site of the disease. Endometriosis is commonly seen in the ovary as chocolate cyst or endometriotic cyst which gives rise to severe abdominal pain. Adhesion formation around the reproductive organs distorts the anatomy and, all of these collectively are responsible for infertility in women. 30%-40% of women will be subfertile. Severe dysmenorrhoea, pelvic pain are the other common presenting complaints. Symptoms of endometriosis do not co-relate well with disease severity.

Investigations:

Pelvic sonography, computed tomography (CT) scan and MRI (magnetic resonance imaging) are useful imaging modalities in visualization of endometriotic cyst.

Transvaginal sonography is useful in identifying endometriotic cyst.
MRI has increased sensitivity over transvaginal sonography.
CT Scan is a useful tool in diagnosing complicated cases like bowel obstruction, kidney obstruction due to endometriosis
Intravenous pyelography and colonic studies are to be performed in case of extra-uterine endometriotic involvement.
CA-125 cancer antigen test has poor sensitivity index in detecting endometriosis.
Laparascopy is the only confirmative but invasive diagnostic tool in endometriosis.


TREATMENT

Medical therapy

1. Progesterone preparation gives promising results in treating endometriosis.
2 .Pain relief due to the disease is best achieved with the use of anti inflammatory drugs.

There can be good disease control and pain relief with medical line of management.

Surgical management

1. Conservative surgery is performed in cases of infertility, adolescent age group and where reproductive function is desired.
2 .Radical surgery is performed in extensive and deep endometriosis.

FAQ's

  • What is endometriosis?
    The tissue present inside the uterus is seen outside in endometriosis. Endometriosis is missed in 7% of normal people and understaged in 50%.
  • What causes Endometriosis?
    The real cause of endometriosis remains unknown. There is a theory that menstrual blood refluxed through the fallopian tubes gets deposited and grows on the pelvic peritoneum and pelvic organs.
  • What is the Surgical Treatment?
    There are are two surgical options radical and conservative. Conservative surgery is rarely curative but is for those women who wishes to maintain her reproductive potential. Radical surgery refers to the removal of uterus,ovaries and endometriotic lesion.
  • What is the role of conservative surgery in endometriosis ?
    The goal is to restore the normal anatomic relationship with view to increase the patients chances of conception and obtain pain relief.
  • Which organs other then reproductive organs are involved in endometriosis?
    Endometriosis may affect the urinary system.gastrointestinal system and rarely seen on the under surface of diaphragm.recently lot of cases are being diagnosed with abdominal wall endometriosis.
  • What are its Symptoms?
    Pelvic pain. Menstrual complaints. Painful intercourse Painful defecation. Infertility. Lower back pain which may radiate down the legs.
  • How do I know wheather I have Endometriosis ?
    Endometriosis is almost always diagnosed laparoscopically. Recognition of endometrioctic lesion is always hampered by excistence of coexisting microscopic lesions in normal looking abdomen.
  • Does endometriosis recur after surgery ?
    Recurrence of symptom rates of 13% and 40% has been seen after follow up of 3&5yrs respectively.Pregnancy to some extent can delay the onset of endometriosis.
  • Will I require further surgical intervention after conservative surgery?
    There is 25% risk of redo surgery after conservative surgery and she is fortunate if she gets pregnant as this rate falls to 10%
  • How does endometriosis cause infertility?
    Endometriosis may affect the urinary system.gastrointestinal system and rarely seen on the under surface of diaphragm.recently lot of cases are being diagnosed with abdominal wall endometriosis.