Endometriosis : diagnosis

Clinical features	Symptoms	Pain
	Pelvic examination	Tenderness
		Nodularities
		Fixed retroverted uterus
		Adnexal masses
Investigation	Ultrasound	Ovarian endometrioma / chocolate cyst
	Diagnostic laparoscopy	Endometrial implant
		Biopsy

Women with endometriosis commonly presented with pain symptoms (dysmenorrhea, dyspareunia, dysuria, dyschezia, abdominal pain, back pain) eventhough some of them may be asymptomatic and only found out incidentally during surgery for other condition.

Pelvic examination may elicit tenderness which can be ill-localized or focal tenderness for example over the posterior fornix or anterior vaginal wall. Nodularities may be appreciated during pelvic examination upon palpation of the uterosacral ligament or upon rectovaginal examination, which may suggest endometrial lesions over the uterosacral ligament and the rectovaginal septum respectively. Adnexal masses found during pelvic examination of a woman with suspected endometriosis may suggest presence of ovarian endometrioma (chocolate cyst). Bimanual examination may revealed fixed retroverted uterus which suggest significant degree of adhesion has occurs.

Pelvic examination - bimanual examination

Pelvic examination - rectovaginal examination

Ultrasound imaging in endometriosis may revealed ovarian endometrioma / chocolate cyst which can be described as homogenous hypoechoic grain-like lesion surrounding by well defined thickened cyst wall.

Ultrasound

Diagnostic laparoscopic examination is the gold standard investigation in diagnosing endometriosis, which allows direct visualization of the endometriotic lesions. During the laparoscopy, usually the discovered endometriotic lesions are removed and biopsy taken and sent for histopathological examination to confirm the diagnosis.

Laparoscopic examination

Laparoscopic examination

Endometriosis

Endometriosis : pathophysiology

The survival and persistence of endometrial implants is maintained by the presence of estrogen hormones. These estrogen-dependent lesions, grow and regress as the estrogen level fluctuating up and down respectively. As it regresses, inflammation occurs and leads to release of various inflammatory mediators which responsible for the pain symptoms in endometriosis. These mediators lead to damage of the surrounding tissues and when healing process take places later, there will be scarring and adhesion which increase the severity and complication of the disease.

Depending on the location of the endometrial implants, the pain symptoms may vary in term of presentation, commonly such as: 1) dysmenorrhea 2) dyspareunia 3) dyschezia 4) dysuria 5) lower abdominal / back pain. Some women may presented with more atypical presentation which may suggest more invasive disease such as hematuria (bladder invasion), hematochezia (bowel invasion), sciatica (nerve invasion), or dyspnea (catamenial pneumothorax).

Endometriosis is a chronic relapsing progressive disorder. as the disease progresses, patient may develop chronic pelvic pain due to the chronic inflammatory process. Besides,patient may suffer from subfertility with all the adhesion which may cause mechanical obstruction of the reproductive route preventing fertilization or implantation to occur properly.

Endometriosis

Endometriosis: pathogenesis

Pathogenesis

There are many theories describing the pathogenesis of endometriosis. These theories can be classified into: 1) in-situ development 2) transplantation / implantation 3) combination of in-situ development and transplantation / implantation.

In-situ development -The cells of that site itself undergo differentiation and become endometrial cells	a)       Germinal epithelium of the ovary
	b)       Embryonic cell
	c)        Coelomic metaplasia
	d)       Metaplasia by inflammation
	e)       Metaplasia by hormonal stimulation
	f)        Metaplasia by induction
	g)       Secondary mullerian system
Transplantation / implantation -The endometrial cells from the uterus lining migrate to other sites	a)       Retrograde menstruation
	b)       Mechanical transplantation
	c)        Benign lymphogenous metastasis
Combination of in-situ development and transplantation/implantation

Among the most widely accepted theories include: 1) retrograde menstruation 2) coelomic metaplasia 3) benign lymphogenous metastasis.

In retrograde menstruation theory, it is said that the menstrual blood contain some viable endometrial tissues, which retrogradely shed into the peritoneal cavity and get attach to the peritoneal cavity, proliferate and produce endometriosis implant.

Coelomic metaplasia theory claims that formation of endometriosis implant is caused by metaplasia of the coelomic epithelium, perhaps induced by environmental factor.

Another theory suggests that shedding menstrual tissue travels from the endometrial cavity through lymphatic channels and veins to distant sites, for example outside the pelvic cavity.

Endometriosis