Endometriosis - Ohana

Question 1

What is the prevalence of endometriosis?

What is the most common site?

Answer 1

4% in fertile women and 40% in infertile women

6-10% from intestinal involvement

Ovary is most common site

Question 2

What are the three theories of endometriosis pathogenesis?

Answer 2

1. Retrograde menstruation (but present in 70-90% of women anyway)
2. Coelomic epithelial metaplasia (covers serosa layers, becomes endometrium-like triggered by inflammation).
3. Induction theory (of K-ras allele)

Increased evidence of genetic component

Reduced immunologic clearance, reduced NK/macrophage activity
Increased inflammation and overactive aromatase associated

Question 3

What are the categorization of morphology of endometriosis?

Answer 3

Red
(red, red-pink or clear)
Most metabolically active and painful

White
(white, yellow-brown and peritoneal defects)

Black
(black and blue lesions)
Can be mistaken for ruggae
Very painful

Question 4

What are the three clinical identities of endometriosis defined?

Answer 4

1. Peritoneal endometriosis.
   Case by case treatment, surgery doesn’t show consensus of improvement
2. Ovarian endometriosis.
   Only excise when symptomatic
   Don’t fenestrate or aspirate, need to excise completely
   Try to preserve fertility
   Using CO2 reduces adhesions
   Need to remove adhesions and nodules for fertility
   Can also give BCP for weeks at a time, also GnRH analog and androgens should help by downregulation
   Couples have a golden year to conceive (60% chance) then IVF
3. Rectovaginal / retrocervical / adenomyosis (outer muscular wall of uterus).
   Shave endometriomas, don’t need to take out if serosa and superficial muscularis
   When multifocal and invasive, bowel may be removed
   Remove lesions in the bladder
   Ureterolysis if in ureters to prevent lumen closure, danger of hydronephrosys