• Credits
  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

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• Introduction

• Q. What is Endometriosis?

  • Endometriosis is the presence of endometrium tissue outside the uterine cavity in ectopic locations

• Q. What are the clinical features of endometriosis?

  • Cyclic pelvic pain
  • Pain on intercourse
  • Infertility

• Q. Is it an inherited disease?

  • It has a polygenic inheritance

• Pathology

• Q. What are the three classical pathological types and locations in endometriosis?

  • Pelvic periotenum- periotoneal endometriosis
  • Ovaries – endometrioma
  • Between rectum and vagina- rectovaginal nodule

• Q. How does endometriosis produce infertility?

  • Pain during intercourse- reduce the frequency
  • Interfere with ovulation
  • Block fallopian tubules
  • Inflammation in the endometrium- prevent implantation

• Q. When does endometriosis typically appear, and when does it disappear?

  • Typically appears at menarche and disappears at menopause
  • Rectovaginal nodules may create a problem even after menopause

• Q. Which hormone is principally involved in pathogenesis, growth, and symptoms of endometriosis?

  • Estrogen

• Q. What are some common theories for the origin of endometriosis?

  • Endometrial tissues moves down the fallopian tubes and into the peritoneum and ovary
  • The mesothelial cells in ectopic location differentiate into endometrial tissue
  • Endometrial tissues passes via lymphatic and veins
  • Hemopoietic stem cells from bone marrow differentiate into endometrial tissue at the ectopic location

• Q. What does the target tissue take up the endometrial tissue?

  • There is defective immune system activation which fails to clear this ectopic tissue
  • There is a change like cell processes in the ectopic tissue, like in cancer cells

• Q. What are the important changes that occur in the endometriosis tissue which is targeted during therapy?

  • Excessive estrogen synthesis
  • Excessive prostaglandin synthesis
  • Progesterone resistance

• Diagnosis

• Q How is a diagnosis of endometriosis made?

  • From history – cyclic pelvic pain starting during menarche
  • Direct visualization of peritoneal endometrial tissue on Laparoscopy
  • Ovarian, endometrial cyst (chocolate cyst) – seen on ultrasound

• Treatment

• Q. Give an outline of the management of endometriosis?

  • Ovarian and rectovaginal endometrioma- removed surgically
  • Pain – NSAIDs and hormonal therapy – block ovarian synthesis
  • Infertility- Surgical removal of endometrial tissue + ART
  • Peritoneal implants- LASER to burn the implants
  • If nothing works for the pain especially- remove both ovaries

• Q. What is the indication for hormonal therapy?

  • It is mainly given for the pain

• Q. Which are the various hormonal agents used in endometriosis?

  • GnRH agonist
  • Danazol
  • Progestin
  • OC pills
  • Aromatase inhibitor – 3rd gen- Letrozole / Anastazole

• Q. Which of these is not used nowadays?

  • Danazol is not used these days
  • It produces a lot of androgenization, some of which are irreversible

• Q. How long is the therapy generally given for pain relief?

  • Generally for six months
  • GnRH agonists act faster- OC pills take more time
  • However, recurrence tends to occur on stopping therapy

• Q. Is estrogen production suppressed by GnRH agonist?

  • No
  • Local estrogen production by endometriosis tissue may remain
  • Peripheral estrogen production (by fat tissue etc.) is not suppressed by GnRH agonist
  • This is where aromatase inhibitors are helpful

• Q. What is the typical algorithm for management as proposed by experts for premenopausal women?

  • Start with continuous OC pills (may cause breakthrough bleeding at six months)
  • If pain is relieved with the OC pill- it may be continued till menopause
  • If pain is still high- add aromatase inhibitor + OC pills
  • If the pain still continues- GnRH agonist and then surgery

• Q. Is there any specific biochemical marker for endometriosis?

  • No
  • CA125 is elevated. However, elevation is nonspecific

• Q. What are the long-term risk with endometriosis?

  • Risk of epithelial ovarian cancer
  • Atherosclerosis

• Q. Which tumor marker can be elevated in patients with Endometriosis?

  • CA-125

• Q. What are the treatment options for patients having pelvic pain due to Endometriosis?

  • In this sequence
    • NSAIDS
    • Continuous OCP
    • GnRH agonist therapy
    • Aromatase inhibitor

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