Endometriosis externa or endometriosis

- is a disease characterized by presence of tissues

morphologically, biologically and functionally similar to
normal endometrium (i.e. it contains functional end glands &
stroma) at ectopic locations other than the uterine mucosa
- is a disease of contrast because it is benign, not a
neoplastic condition but however it is locally invasive,
disseminates widely & also has malignant transformation
potential
- Prevalence: 10% ; 30-40% in infertile women; increased
prevalence due to:
Real increase
Delayed marriage
Postponement of 1st conception

Apparent increase
ed diagnostic procedures
(laparoscopy, laparotomy)
ed awareness about disease
complex among gynaecologists

Small family norm

- Sites of endometriosis:
Abdominal
Ovary (+nce of
gonadal
steroids)
Pelvic peritoneum

Pouch of Douglas /
Cul-de-sac /
rectovaginal pouch
Uterosacral
ligament
Broad ligament

Extra-abdominal
Umbilicus

Remote
Lungs

Abdominal scar of
hysterectomy,
myomectomy,
tubectomy,
caesarean section
Episiotomy scar

Pleura

Vagina

Deep tissues of
thighs
Nasal mucosa

Cervix

Deep tissues of
arms

Rectovaginal
septum
Rectum
Pelvic lymph nodes
Gut, appendix
KUB
Abdominal:
Extrabdominal:
structures below
uncommon; only in
the level of
susceptible women
umbilicus; most
common site;
uncommon ones
are KUB, gut,
appendix

Remote: rare

- Pathogenesis:
Theory
Retrograde
menstruation
(Sampson's
theory)

Coelomic
metaplasia
(Meyer & Ivanoff)

Direct
implantation

Description
Menstruation-RM per se
thru UTs + genetic
factorsimplantation
(ovaries, USL) --- +
ovarian hormones--cyclic growth &
shedding
endometriosis
Chronic irritation of
peritoneum by blood +
mullerian t/s remnants
in peritoneum
-------CM------normal
endometrium
Implantation & growth
of endometrial &
decidual t/s at ectopic

Applicable to
Pelvic
endometriosis

Endometriosis of
umbilicus,
abdominal
viscera, pelvic
peritoneum, RVS
Endometriosis of
abdominal scar,
episiotomy scar,

Lymphatic theory
(Halban)

Vascular theory

sites in susceptible
women
Normal endometrium---metastasize thru
draining lymphatic
channels of uterus---to
pelvic LNs
Hematogenous spread

Environment
theory

Somatic mutations of
cells due to
environmental
pollutants, dioxins

Genetic &
immunological
factors

Genetic
factors:
<10% pts
6-7 times
increased
incidence
in 1st
degree
relatives
Multifactor
ial
inheritanc
e

Immunologi
cal factors:
Defect in
local
cellular
immunity
growth
Activated
macrophag
es:
increased
phagocytos
is,
decreased
motility of
sperm-no
fertilization;
secrete IL-

vagina, cervix
Endometriosis of
pelvic lymph
nodes

Endometriosis of
distant sites
(lungs, pleura,
arms, thighs,
nasal mucosa)
Ovarian & deep
infiltrating
endometriotic
lesions
Endometriosis in
1st degree
relatives; pelvic
endometriosis
with subclinical
inflammation
with increased
peritoneal fluid

1, TNFalpha,
cytokines,
integrins,
angiogenic
factors
growth;
decreased
apoptosis
- Pathology:
- Under the action of ovarian hormones, changes in
endometrium (glands & stroma) in ectopic sites take place
i.e proliferative changes / growth but no secretory
changes due to deficiency of steroid receptors
- periodical or cyclical growth & shedding until menopause
- periodically shed blood:
a) spill----blood---irritant---surrounding dense t/s rxn--adhesion & fibrosis---puckering of peritoneum; dense
adhesions amongst pelvic strts but fallopian tubes
remain patent
b) encysted-----cyst has 2 fates
i)
cyst----tenseruptures
ii) cyst----enlarges----shrinks in betn periods as
serum is absorbed-----cyst content is chocolate
colored----chocolate cyst----common site:
ovary------endometrial cyst/endometrioma also
called chocolate cyst due to hemmorhagic
follicular / corpus luteum cyst or due to bleeding
into cystadenoma
Gross / Naked eye
appearance
- depends upon:
i)
organ involved
ii)
extent of lesion

Microscopic
- contains endometrial t/s
(both glands & stroma)
with or without

iii)

surrounding t/s rxn

- powder burn/black dot/

match stick spots
appearance in USL, POD in
pelvic endometriosis
- chocolate cyst of varying
sizes (bluish colorations)
of ovary (usually B/L);
ovary freq involved

hemosiderin (blood
pigment) laden
macrophages or
pseudoxanthoma cells
adjacent to lining
epithelium
- cyst wall composed of
fibrous t/s & compressed
outer ovarian cortex
- cyst wall lining absent or
flattened/cuboidal or with
granulation t/s due to
pressure effect inside cyst
wall

- subovarian adhesions;
ovaries adherent to pelvic
strts including rectum & SC
- subtle appearances:
i)
red flame shaped
areas
ii)
red polypoid areas
iii) white peritoneal
areas
iv) circular peritoneal
defects
v)
yellow brown patches
- fibrosis & scarring in
peritoneum surrounding
implants (puckering):
typical finding
- Diagnosis:
- Clinical diagnosis
Classic symptoms

Physical examination

- increasing secondary
dysmenorrhea
- dyspareunia
- infertility

- pelvic examination
- abdominal examination
- rectal or rectovaginal
examination

- chronic pelvic pain

- abdominal pain
- menstrual abnormality
- Serum markers
CA-125
-

MCP-1 (Monocyte
Chemotactic protein)
not specific as increased in - increased in peritoneal fluid
epithelial ovarian carcinoma
of women with endometriosis
seen only in severe
endometriosis
helpful for F/Up cases (to
detect any recurrence after
therapy & to assess
therapeutic response)
Imaging
Ultrasonogr
aphy

not much
helpful in
diagnosis of
peritoneal
endometriosis
TVS
(Transvaginal
ultrasonograp
hy) can detect
ovarian

CT

MRI
(Magnetic
Resonance
Imaging)
better than diagnostic
US in
tool
diagnosis

useful for
deep
infiltrating
endometriosi
s

Colonoscopy,
rectosigmoido
scopy,
cystoscopy
done when
respective
organs are
involved

endometriom
as
- TVS &
endorectal
ultrasound
can detect
rectosigmoid
endometriosis

characteristi
c
hyperintensit
y on T1
weighted
image &
hypointensit
y on T2
weighted
image
- Gold standard for confirmation: double puncture
laparoscopy or laparotomy
Benefits
Confirmation of lesion with site, size & extent: classic lesion
of pelvic endometriosis (powder burn or match stick spots on
peritoneum of PODfindings may be recorded on video/DVD
(ROG-2006))
Biopsy can be taken at the same time (microscopically:
endometrial glands, stroma, hemosiderin-laden
macrophages or pseudoxanthoma cells)
Staging can be done
Extent of adhesions could be recorded
Opportunity to do laparoscopic surgery if needed
- Biopsy confirmation of the excised lesion: ideal; but ve
histology does not exclude it
- Staging or classification of endometriosis based on
i)
appearance, size & depth of peritoneal implants
ii)
appearance, size & depth of ovarian implants
iii) degree of cul-de-sac obliteration
iv) presence, extent & type of adnexal adhesion
- Staging of diagnosed endometriosis based on laparoscopic
findings:
i) to predict prognosis
ii) to choose therapy

iii) to evaluate T/t protocol

- Stage determined by adding specific points given to each
- American Fertility Society (AFS) scoring
- Limitations :
laparoscopy or laparotomy has to be done
interobserver & intraobserver variations
staging not correlated with fertility outcome
staging not correlated with optimum mode of therapy
no correlation with extent of disease & degree of symptoms

- Differential diagnosis
i) Chronic pelvic infection
ii) Ovarian endometrioma
iii) Rupture of chocolate cyst
- Complications
i)
Endocrinopathy

ii)
iii)
iv)
v)

Infection of chocolate cyst

Rupture of chocolate cyst
Intestinal & ureteral obstruction