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Mochamad Anwar
Subdivision of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology Faculty of Medicine, Gadjah Mada University
DEFINITION
ENDOMETRIOSIS IS DEFINED AS THE PRESENCE OF ENDOMETRIAL TISSUE (GLAND AND STROMA) OUTSIDE THE UTERINE CAVITY (Oestrogen dependent disease)
INTERNAL
EXTERNAL
ADENOMYOSIS
LOCALIZATION OF ENDOMETRIOSIS
INTRA-PELVIC
EXTRA-PELVIC
GYNECOLOGIC SITE
NON-GYNECOLOGIC SITE
ETIOLOGY
Ectopic transplantation of endometrial tissue Coelomic metaplasia The induction theory
GENETIC IMMUNOLOGIC
FACTORS
FACTORS
Ectopic transplantation
Endometriosis is caused by the seeding or
implantation of endometrial cells by transtubal regurgitation during menstruation (Sampson hypothesis, 1920) Ovarian endometriosis may be caused by either retrograde menstruation or by lymphatic flow from the uterus to the ovary.
COELOMIC METAPLASIA
The transformation (metaplasia) of
coelomic epithelium into endometrial tissue. This theory has not been supported by either strong clinical or experimental data.
Induction theory
The Induction theory is, in principle, an
extension of the coelomic metaplasia theory. An edogenous (undefined) biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissue. This theory has been supported by experimental in Rabbits, but not in women and primates.
GENETIC FACTORS
The risk of endometriosis is seven
times greater if a first-degree relative has been affected by endometriosis. A relative risk for endometriosis of 7.2 has been found in mothers and sisters. A 75% incidence has been noted in homozygotic twins of patients with endometriosis.
Immunologic Factors
Not all women who have retrograde
menstruation develop endometriosis. Endometriosis may develop as a result of reduced immunologic clearence of viable endometrial cells from the pelvic cavity. Natural Killer (NK) cell theory. Cytokines theory (alfa-TNF). Macrophage-epidermal growth factor (EGF), macrophage-derived growth factor (MDGF).
Cessation of symptoms
CLINICAL SYMPTOMS
Clinical Examination
In many women with endometriosis, no
abnormality is detected during the clinical examination. Uterosacral or cul-de-sac nodularity, painful swelling of the rectovaginal septum and unilateral ovarian (cystic) enlargement. Uterus is often in fixed retroversion and the mobility of the ovaries and fallopian tubes is reduced
Histological Confirmation
Microscopic endometriosis is defined as the presence of endometrial gland and stroma, with or without hemosiderin-laden macrophage.
Laboratory test
There is no blood test available for
the diagnosis of endometriosis. Serial CA-125 determination may be useful to predict the recurrence of endometriosis after therapy.
DECREASING OF FERTILITY
* ABNORMAL LEVEL OF PERITONEAL
PROSTAGLANDINS AND MACROPHAGES * DISTURBANCES IN FOLLICULOGENESIS * DISRUPTION OF OVULATORY CORPUS LUTEUM FUNCTION
THE MORE FREQUENT USE OF LAPAROSCOPY TO INVESTIGATE PELVIC PAIN HAS REVOLUTIONISED BOTH THE DIAGNOSIS AND THERAPEUTIC ASPECS OF ENDOMETRIOSIS.
EARLY ENDOMETRIOSIS
CLASSIFICATION
Appearance and Size Depth of peritoneal and Ovarian
implants The presence, extent, and type of adnexal adhesions The degree of cul-de-sac oblitaretion
( r-AFS )
PLANNING OF TREATMENT
TREATMENT OPTIONS
OBSERVATION
MEDICAL
SURGERY
LAPAROTOMY LAPAROSCOPY
NO TREATMENT
PROGESTAGENS
INHIBITS GONADOTROPHIC FUNCTION
HYPOESTROGENICITY + PSEUDOPREGNANCY
ENDOMETRIAL ATROPHY
SIDE EFFECTS
HIGH DENSITY LIPOPROTEIN INFERTILITY
Progestogens
Medroxy progesterone acetate Megestrol acetate Lynestrenol Dydrogesterone
EFFECTIVITY OF PROGESTAGEN :
PSEUDOPREGNANCY-STATE
SIDE EFFECTS
BREAKTHROUGH BLEEDING NUSEA, BREAST TENDERNESS WEIGHT GAIN AND DEPRESSION
Antiprogestins
Gestrinone Danazol
DANAZOL
is a derivative of ethisterone with androgenic properties Reduction of LH and FSH level Reducing of estradiol level Supressing ovulation Inhibiting endometrial growth
SIDE EFFECTS Weight gain, muscle cramps Acne, nausea, water retention Hot flashes, dry vaginal and Deppresion.
GnRH-Agonist
Suppresion of Gonadotrophin secretion Reduction of FSH and LH Complete ovarian suppression complete endometrial atrophy
Gonadrotropin-RH
Leuprolide Goserelin
Buserelin
Nafarelin Tryptorelin Tapros
Subcutaneous injections
Depot injections Implant
Dysmenorrhoea
Counseling
Total abdominal hysterectomy and salphingooophorectomy
Reproductive potential
Medical
Combined
Counseling
Summary
The procedure of laparoscopic exploration in
women pelvic pain is important to verify early endometriosis. The basis of all medical therapy is to control endometriosis by supression of ovarian function. The treatment options for endometriosis should be determined by : age, symptoms, reproductive status and severity of condition.
Thank You