Medical brain notes 42

  Endometriosis Endometriosis  is the presence of endometrial glands E  and stroma in any extrauterine site, and may be sus-pected based on history, symptoms, and physical examination as well as laboratory and imaging informa-tion. Like the endometrial tissue from which it is derived, endometriosis implants and cysts respond to the hormonal fluctuations of the menstrual cycle. Laparotomy or laparos-copy may reveal lesions consistent with endometriosis, but because lesions may be small or atypical or caused by pathology other than endometriosis,  only proven tissue biopsydiagnosis is diagnostic.  Many women with endometriosis areasymptomatic, and diagnosis is confirmed only when sur- gery is performed for other indications. It is estimated that 7% to 10% of women in the gen-eral population have endometriosis. Pelvic endometriosis is present in 6% to 43% of women undergoing steriliza-tion, 12% to 32% of women undergoing laparoscopy for pelvic pain, and 21% to 48% ...

  PATHOGENESIS   The exact mechanisms by which endometriosis develops are not clearly understood. Three major theories are com-monly cited.   ·       Direct implantation of endometrial cells, typically by means of  retrograde menstruation.  This mechanism is consistent with the occurrence of pelvic endome-triosis and its predilection for the ovaries and pelvic peritoneum, as well as for sites such as an abdominal incision or episiotomy scar. Direct implantation is com-monly referred to as Sampson’s theory because of his experimental work that showed the possibility of such a mechanism.   ·       Vascular and lymphatic dissemination  of endome-trial cells (Halban’s theory). Distant sites of endometrio-sis can be explained by this process (i.e., endometriosis in locations such as lymph nodes, the pleural cavity, and kidney).   ·       Coelomic metaplasia  of multipotenti...

  PATHOLOGY   Endometriosis is found on the ovaries in most patients and is typically bilateral. Other common pelvic structures involved include the pouch of Douglas (particularly the uterosacral ligaments and rectovaginal septum), the round ligament, the fallopian tubes, and the sigmoid colon (Fig. 29.1 and Table 29.1). On rare occasions, distant endometriosis is found in abdominal surgical scars, the umbilicus, and various organs outside the pelvic cavity.   The gross appearance of endometriosis varies considerably and includes the following forms:   ·        Small (1-mm), clear or white lesions ·        Small, dark red (“mulberry”) or brown (“powder burn”) lesions ·        Cysts filled with dark-red or brown hemosiderin-laden fluid (“chocolate” cysts) ·        Dark-red or blue “domes” that may reach 15–20 cm in size   Reactive fibrosis frequ...

  SIGNS AND SYMPTOMS   Women with endometriosis demonstrate a wide variety of symp-toms.  The nature and severity of symptoms may not matcheither the location or extent of the disease. Women with grossly extensive endometriosis may have few symptoms, whereas those with minimal gross endometriosis may have severe pain.  Endometriosis may also be asymptomatic.  The pain associated with endometriosis is thought to depend more upon the depth of invasion of the implants rather than on the number or extent of the superficial implants.  The classicsymptoms of endometriosis include progressive  dysmenorrhea  and deep  dyspareunia. Some patients experience chronic,unremitting pelvic discomfort along with dysmenorrhea and dyspareunia. Chronic pelvic pain may be related to the adhesions and pelvic scarring found in association with endometriosis.   Dysmenorrhea caused by endometriosis is not directly related to the amount of visible disease. In man...

  DIFFERENTIAL DIAGNOSIS Depending on the symptoms, the differential diagnosis will change. In patients with chronic abdominal pain, diagnoses such as chronic pelvic inflammatory disease, pelvic adhe-sions, gastrointestinal dysfunction, and other etiologies of chronic pelvic pain should be considered. In patients with dysmenorrhea, both primary dysmenorrhea and secondary dysmenorrhea should be considered. In patients with dys-pareunia, differential diagnoses include chronic pelvic inflammatory disease, ovarian cysts, and symptomatic uter-ine retroversion. Sudden abdominal pain may be caused by a ruptured endometrioma as well as by ectopic pregnancy, acute pelvic inflammatory disease, adnexal torsion, and rupture of a corpus luteum cyst or ovarian neoplasm.

  DIAGNOSIS   Endometriosis should be suspected in patients with the pre-viously described symptoms. Many symptomatic women have normal findings on pelvic examination.  The diagnosis ofendometriosis can be substantiated only by direct visualization during laparoscopy or laparotomy confirmed by tissue biopsy.  Thepresence of two or more of the following histologic fea-tures is used as the threshold criteria for the diagnosis by a pathologist:   ·    Endometrial epithelium   ·    Endometrial glands   ·    Endometrial stroma   ·    Hemosiderin-laden macrophages   Because tissue confirmation of the diagnosis of endo-metriosis requires a surgical procedure, investigators have searched for a noninvasive alternative. Increased serum CA-125 levels have been correlated with moderate to severe endometriosis. However, because CA-125 levels may be elevated in many conditions, the clinical utility of using it as a d...

  TREATMENT Available therapies include expectant, hormonal, surgical, and combination medical-and-surgical treatment. The choice of treatment depends on the patient’s individual  circumstances, which include (1) the presenting symptoms and their severity, (2) the location and severity of endo-metriosis, and (3) the desire for future childbearing.   No treatment provides a permanent cure. Total abdominal hys-terectomy with bilateral salpingo-oophorectomy is associ-ated with a 10% risk of recurrent symptoms and a 4% risk of additional endometriosis. Reasonable goals for manage-ment of endometriosis include reduction in pelvic pain, minimizing surgical intervention, and preserving fertility. Expectant Management   Patients can be treated expectantly (i.e., without either medical or surgical therapy) in some selected cases, includ-ing patients with limited disease whose symptoms are minimal or nonexistent or patients who are attempting to conceive. Because endometriosis...