ABC OF : ENDOMETRIOSIS. MAY BE USEFUL.       ***** ENDOMETRIOSIS :- MORE THAN 1 MILLION CASES PER YEAR (INDIA)....... TREATABLE BY A MEDICAL PROFESSIONALS....... REQUIRES A MEDICAL DIAGNOSIS....... LAB TESTS OR IMAGING OFTEN REQUIRED....... CHRONIC: CAN LAST FOR YEARS OR BE LIFELONG....... ** CONSULT A DOCTOR FOR MEDICAL ADVICE....... *** ENDOMETRIOSIS is an estrogen-dependent disease wherein endometrial-like tissue is found outside the uterus inducing a chronic inflammatory response.......   Pelvic organs (esp ovaries) & peritoneum are frequently affected....... *** SYMPTOMS :- MAIN CLINICAL FEATURES INCLUDE: CHRONIC PELVIC PAIN (found in 70-80% of patients) DYSPAREUNIA (suggests deep posterior infiltration) INFERTILITY (21% prevalence rate) OTHER SYMPTOMS may include severe dysmenorrhea, pain on ovulation, noncyclical pelvic pain, cyclical bowel or bladder symptoms w/ or w/o abnormal bleeding or pain, chronic fatigue, or dyschezia....... IN ADOLESCENTS, endometriosis is the most common cause of SECONDARY DYSMENORRHOEA....... Although it is vital to consider the patient's complaints affecting physical, mental & social well-being, it should be noted that patients w/ endometriosis may be completely ASYMPTOMATIC (w/ 2-22% prevalence rate).......   ***** DIAGNOSIS :- Diagnosis of endometriosis is made after taking the PATIENT'S HISTORY & doing PHYSICAL EXAMINATION LABORATORY TESTS, LAPAROSCOPY, & IMAGING studies are performed as well to confirm diagnosis.  *** PATIENT'S HISTORY :- Should include: Age (reproductive year, most commonly at 25-29 yr old) In utero exposure to environmental toxins like diethylstilbestrol which increases the incidence of endometriosis Family history of endometriosis (7x higher risk than w/ no family history) *** PHYSICAL EXAMINATION :- Ideally done during early menses because endometrial implants are likely to be largest & deep infiltrating, hence more easily detectable Diagnosis is more definite if deeply infiltrative nodules are found on the uterosacral ligaments or in pouch of Douglas, &/or lesions are directly seen in the vagina or cervix Note that there may be no abnormal findings on physical exam For patients who are not sexually active, a rectal-abdominal exam may be better tolerated than a vag-abdominal exam A cotton swab can be inserted into the vagina to document patency & exclude complete or partially obstructive anomalies such as a transverse vaginal septum, imperforate or microperforate hymen, or an obstructed hemivagina OTHER FREQUENT FINDINGS : Pain w/ uterine movement or pelvic tenderness Tender, enlarged adnexal masses Fixation of adnexa or uterus in a retroverted position *** LABORATORY TESTS :- Urinalysis & urine culture to identify pain originating in the urinary tract (eg cystitis, stones) Pregnancy test & tests for sexually transmitted infection (STI) like gonorrhea, chlamydia, when appropriate....... *** LAPAROSCOPY :- Gold standard for diagnosis, unless lesions are visible in the vagina May also be used for therapeutic purposes Should not be done during or w/in 3 mth of hormonal treatment to avoid under-diagnosis Biopsy & histopathologic study of at least one lesion is ideal 3 cardinal features (ie ectopic endometrial glands, ectopic endometrial stroma, & hemorrhage into adjacent tissue) should be present In adolescents, features of endometriosis may be atypical (ie clear vesicles & red lesions) A negative laparoscopy does not exclude the diagnosis of endometriosis Depending on the severity of the disease found, it is best to remove the endometriotic lesion at the same time Differential diagnoses (eg endosalpingiosis, mesothelial hyperplasia, hemosiderin deposition, hemangiomas, adrenal rests, inflammatory changes, splenosis & reactions to oil-based radiographic dyes) can be excluded by biopsy Laparoscopic Classification (based on location, extent & severity of lesions) : Stages based on American Fertility Society (AFS) Minimal disease (stage I) - characterized by isolated implants & no significant adhesions Mild endometriosis (stage II) - consists of superficial implants <5 cm in aggregate, scattered on the peritoneum & ovaries; with no significant adhesions Moderate disease (stage III) - exhibits multiple implants, both superficial & invasive; peritubal & periovarian adhesion may be evident Severe disease (stage IV) - characterized by multiple superficial & deep implants, including large ovarian endometriomas; filmy & dense adhesions are usually present Severity of symptoms does not match w/ the above stages....... *** IMAGING STUDIES :- ** Transvaginal Sonography (TVS) Considered the 1st-LINE IMAGING TOOL to examine suspected endometriosis Should be performed to determine whether a pelvic mass or structural anomaly is present USEFUL IN DIAGNOSING OR EXCLUDING RECTAL ENDOMETRIOSIS May IDENTIFY an ovarian endometrioma & help identify other structural causes of pelvic pain, such as ovarian cysts, torsion, tumors, genital tract anomalies & appendicitis DISTINGUISHES endometrioma from other ovarian cysts w/ 83% sensitivity & 89% specificity Ovarian endometrioma may be diagnosed in premenopausal women w/ findings of ground glass echogenicity & 1-4 compartments & absence of papillary structures w/ blood flow ** MAGNETIC RESONANCE IMAGING (MRI) : May be helpful in some cases to better define an abnormality suspected by sonography Detects ovarian endometrial cysts w/ 90% sensitivity & 98% specificity Provides exact location of deep retroperitoneal lesion May be used as part of pre-op workup, but should not be used as 1st-line ** MISCELLANEOUS TESTS : Serum CA-125 Women w/ endometriosis may have HIGH serum CA-125 concentration NO VALUE AS DIAGNOSTIC TOOL in endometriosis ALSO ELEVATED in ovarian epithelial neoplasia, myoma, adenomyosis, acute PID, ovarian cyst, pregnancy....... ** BIOPSY : May be considered in suspected endometriosis lesions & endometriomas to help confirm the diagnosis & exclude possible malignancy In patients w/ endometriosis, prevalence of ovarian cancer is <1% *** TREATMENT :- Management of endometriosis includes medical therapy w/ first-line agents oral contraceptives & progestins....... Second-line agents include Danazol, gonadotropin-releasing hormone (GnRH) agonists, Levonorgestrel intrauterine system, & aromatase inhibitors....... Supportive therapy w/ nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to provide pain relief....... Surgery should only be done in women w/ endometriosis-related pain after medical treatment has failed....... Combined medical/surgical therapy is medical therapy given before &/or after surgery.......  

Primary infertility pt with the usg reportpl guide for treatment

F.24. Married for 2yrs. Anxious to conceive. Cycle regular and average flow.

43 year old lady with complaints of Menorrhagia for the past 7 years, on investigation left ovarian cyst was found.. Hysterectomy done , Ovarian cyst measuring 10 x 8 x 4 cm. On cut section cystic area showed cheesy material .. Images attached , Diagnosis ??

What is your opinion of doing bilateral salpingo Oophorectomy at the time of hysterectomy. Coz patients are of the opinion that if they undergo Tubectomy,they will land with a BIGGER operation that is hysterectomy.therefore some people come asking to do a hysterectomy after child bearing. If only hysterectomy is done when indicated and later if they require laparotomy for ovarian cyst /tumour,patients question "why you didn't remove these appendages earlier. One patient had hysterectomy,followed by laparotomy again for an ovarian cyst,later another cyst on other side -third surgery .she again developed cystic mass in the pelvis for which she had fourth surgery . Though we leave ovaries ,their function gradually comes down after hysterectomy and they have PMS and osteoporosis. When I have to do a hysterectomy ,I remove the appendages if she is above 40 years and retain them if she is young. What are your opinions