Leah Orta, MS III OB/GYN Clerkship Dr. Flix Hernndez Rodrguez Dr.

Miguel Vega Gilormini

 Discuss the patients gynecological and obstetric

history
Present the findings of the Exploratory Laparoscopy

performed on the patient

Define Endometriosis Discuss the epidemiology, etiological theories,

symptoms, diagnosis, and management of endometriosis

Patients OB/GYN History

 Age: 30 y/o Sex: Female Ethnicity: Puerto Rican Civil Status: Married Town of Residence: Ponce, PR Occupation: Pharmaceutical representative

Religion: Roman Catholic

Source: Patient: Reliable Admission Date: 10/23/09

 Chief Complaint:

Pelvic pain of more than 5 years duration

History of Present Illness:

Case of 30 y/0 female G2P1A1 LMP unknown who presents with chronic pelvic pain of more than 5 years duration and failure to conceive for the past year. The patient reports heavy bleeding during menses, moderate to severe pelvic pain associated with menstruation, and deep pelvic pain during sexual intercourse. Pain is generalized with a dull quality (5-6/10)

that progresses to stabbing and tearing quality (10/10) during menses,

and it is relieved with use of NSAIDs and aggravated with menstruation. Patient denies history of chlamydia, gonorrhea, or other STIs. The patient had not undergone evaluation prior to her presentation.

 Past Medical History:

Medical conditions:

GIT: Gastritis, Reflux CNS: Migraine

Hospitalizations: Delivery Surgical procedure: None

Medications: None
Allergies: None Transfusions: None

 Family History: Non-contributory

Social History:

Married with 1 child

Actively working Habits: None

Review of Systems: Non-contributory

 Vital Signs:

BP: 113/61 mmHg Ht: 5 2

T: 37.0C Wt: 137 lbs

P: 80 bpm BMI: 25.1

R: 18 breaths/min

General appearance: Calm, alert and oriented. () diaphoresis Skin: (-) jaundice, (-) rash, (-) ecchymoses, (-) petechiae HEENT: Face is symmetric; eyes and pupils are symmetric; teeth are

intact
Neck: No pain or weakness during neck movements. Carotid pulse felt,

no bruits heard.
Shoulders and Back: (-) Jordan Sign, symmetrical movement

 Thorax:

Costovertebral joints: No tenderness or pain Heart: Regular rate and rhythm. No murmurs, rubs, or gallops Lungs: Clear to auscultation bilaterally Breasts: No masses or nipple discharge

Abdomen: Flat, non-tender abdomen. No bruits heard. Bowel sounds

present.
Pelvic: Pelvic exam under anesthesia revealed anteverted uterus, posterior

cervix, and uterine size of 8cm

Extremities: All pulses felt bilaterally. (-) edema

Differential Diagnosis Endometriosis

(+) Age Dysmenorrhea Dyspareunia Infertility Pain relieved by NSAIDs Age Generalized pelvic pain Infertility Age Pain associated with menses

(-) No prior direct observation studies to confirm presence of endometrial implants Negative history of GC or chlamydia Associated symptoms including dyspareunia and infertility

Pelvic Inflammatory Disease Primary Dysmenorrhea

Irritable Bowel Syndrome Age Pelvic Pain Dyspareunia

Negative history of small and/or large bowel symptoms

Diagnostic Findings

 Abdominal cavity was entered through umbilical incision and pelvic

cavity visualized through video laparoscopy

Left ovary was immediately evident:

Left and right fallopian tubes were visualized and seen to be adherent to left ovary

Right ovary was not visualized Left ovary was punctured and drained Chocolate-colored fluid exited the left ovarian cyst

Endometrioma capsule was removed and sent for pathology

Cromotubation was performed using methylene blue dye: both

tubes were patent

Left Ovary and Uterus

Left Ovary and Left Fallopian Tube

Endometrioma Punctured

Endometrioma Capsule Removed

 Preoperative Diagnosis: Chronic Pelvic Pain Postoperative Diagnosis: Endometriosis Procedure: Operative Triple Puncture Video Laparoscopy with Left

Ovarian Cystectomy and Cromotubation

Physician: Dr. Miguel Vega Gilormini Estimated Blood Loss: 100ml

Drains: None
Complications: None Specimen: Left Ovarian Endometrioma Capsule

 Source:

Endometrioma, capsule

Gross Description:

Left endometrioma; specimen consists of few irregular fragments of brown, soft tissue measuring in aggregate 3.5

x 3 x 0.6 cm.

Final Diagnosis: Microscopic diagnosis:

Endometrioma

Definition, Epidemiology, Etiological Theories, Symptoms, Diagnosis, and Management

 Definition:

The presence of endometrial glands and stroma outside of the uterine cavity [1]

 Prevalence[2]:

Worldwide: 90 million women suffer from endometriosis USA: 5-7 million women (1 in 10)

PR: 5% of PR women (1 in 20)

Overall, found in:

3-10% of women of reproductive age

25-35% of infertile women

Peak Age Group: 20-40 year olds Prevalence is not affected by ethnicity or SES

 Implantation Theory:

Retrograde reflux of menstrual tissue from the fallopian tubes during menstruation

Most widely accepted theory

 Celomic Metaplasia Theory:

Mesothelium covering ovaries invaginates into the ovaries, then undergoes metaplasia into endometrial tissue

Embryonic Rests Theory:

Mllerian remnants in the rectovaginal region differentiate into endometrial tissue

 Having a first line relative

Environmental exposure

with endometriosis (7-9x

increased risk)
Shorter menstrual cycles Longer bleeding during

to dioxins (pollutants)
Consuming 1 or more

alcoholic drinks per week

Use of pads AND

menstruation
Early menarche

tampons
Never using OCPs

 Symptoms are non-specific and they tend to be strongest pre-

menstrually, subsiding after cessation of menses. These

include:

Generalized pelvic pain: most common symptom

Back pain
Dyspareunia: pain with sexual intercourse Loin pain

Dyschezia: pain with defecation

Pain with micturition Infertility

Dysmenorrhea Primary: due to imbalance between PGE2 and PGI2 Adenomyosis Myomas Infection

Dyspareunia Diminished lubrication or vaginal expansion due to decreased arousal GIT causes: IBS, constipation Infection Musculoskeletal causes: levator spasm, pelvic relaxation Pelvic vascular congestion Urinary causes: interstitial cystitis

Pelvic Pain Endometritis

Infertility Anovulation

Neoplasms Nongynecological Ovarian torsion

Cervical factors: mucus, stenosis Male infertility Luteal phase deficiency Tubal disease or infection

Cervical Stenosis

Pelvic adhesions PID Sexual or physical abuse

 Physical limitations to conducting household

chores, sexual relationships, work, exercise, social activities, and childcare.

Decrease in the quality of work due to symptoms
Absenteeism: on average 33. days per year Truncated career growth due to absenteeism and

decreased quality of work

Changes in appetite

 Direct visualization of lesions with histological confirmation is

the gold-standard
Positive histology confirms the diagnosis, but negative

histology does not exclude it

Histological examination should confirm the presence of at

least two of the following features:

Hemosiderin-laden macrophages Endometrial epithelium Endometrial glands Endometrial stroma

[2]

White plaques & Clear vesicles

Blue-black lesions

Newly formed blood vessels

[2]

[2]

 Physical Examination:

Tender nodules in the posterior vaginal fornix Uterine motion tenderness A fixed and retroverted uterus Tender adnexal masses resulting from endometriomas

 Imaging:

Transvaginal ultrasound (TVS) has no value in diagnosing peritoneal endometriosis, but it is a useful tool both to

make and to exclude the diagnosis of ovarian

endometrioma and retroperitoneal and uterosacral lesions

MRI has limited value as a diagnostic tool: it is more useful for the diagnosis of an endometrial cyst

CT Scan has not been studied or promoted as a diagnostic

imaging modality

 Serum markers:

CA 125:

Best known for its use in the diagnosis or monitoring of ovarian cancer

Useful marker for endometriosis monitoring and

treatment follow-up

Elevations over 35 IU per ml are considered suspicious for endometriosis when correlated with symptoms

 Serum markers:

CA 19-9:

Inferior sensitivity to CA 125, but may be of some use in determining disease severity

IL-6:

At a cutoff value of 2pg/mL, may be more sensitive and specific than CA 125

TNF-:

With elevations in the peritoneal fluid, has a sensitivity of 1 and specificity of 0.89.

Endometriosis suspected based on history and physical examination

Fertility not desired

Infertility with other causes ruled out

OCPs or Progestogens

Laparoscopy

If no improvement:
GnRH analogues If no improvement: Laparoscopy and surgical treatment If no improvement: Hysterectomy and oophorectomy

Surgical Excision of lesions

 Depot MDPA (Depo-Provera) MDPA (Provera) Combined OCPs

Levonorgestrel IUD (Mirena)

GnRH analogues (Lupron, Zoladex) Nafarelin (Synarel) Danazol Gestrinone

 Defined as failure to conceive for 1 year while having

unprotected sexual intercourse

Management in patients with endometriosis includes:

Ovarian Stimulation Intrauterine Insemination: improves fertility in minimal to mild endometriosis, especially with ovarian stimulation

In-vitro Fertilization: appropriate when tubal function is compromised, male factor infertility is present, and/or other treatments have failed

1.

Mounsey, AL, Wilgus, A, & Slawson, DC. Diagnosis and Management of Endometriosis. American Family Physician 2006; 74.4: 594-602.

2.

Flores, I. 2009.Endometriosis: La enfermedad enigmtica. [Powerpoint slides] . Retrieved from Ponce School of Medicine on October 26, 2009.

3.

Fourquet, J, Gao, X, Zavala, D, Orengo, JC, Abac, S, Ruiz, A, Laboy, J, & Flores, I. Patients report on how endometriosis affects health, work, and daily life. NIH-PA Author Manuscript. 2009. Retrieved from Ponce School of Medicine on October 26, 2009.

4.

Kennedy, S, Bergqvist, A, Chapron, C, DHooghe, T, Dunselman, G, Greb, R, Hummelshoj, L, Prentice, A, & Saridogan, E. ESHRE guideline for the diagnosis and treatment of endometriosis. Human Reproduction. 2005; 1-7.