Endometriosis - Overview (pathophysiology, differential diagnosis, investigations and treatment)

hello in this video we're going to talk about endometriosis which is the presence of endometrial glands and stroma outside the uterine cavity and the uterine musculature so here is a girl lady with endometriosis and during period she gets terrible period pain and pelvic pain let's first revise some Anatomy to understand endometriosis so here's a female genital tract the vagina cervix uterus and ovary the fallopian tube is here also known as a uterine tube zooming into the uterus let's talk about the layers so the innermost layer which is closest to the cavity the uterine cavity this first layer is called the endometrium and below it is the muscular myometrium and below that is a peri made me trium along the myometrium you have branches of the uterine artery which has more branches called these spiral arteries that actually go all the way up to the endometrium these spiral arteries are what helps the endometrium grow during each menstrual cycle because it helps deliver hormones and nutrients the endometrial layer the endometrium is the layer which sheds during periods and a new layer will grow and essentially the endometrium becomes sick once again however a woman with a normal reproductive tract can develop endometriosis and as we have learned endometriosis is where you have the presence of endometrial tissue outside the uterine cavity and neutral musculature and because it's endometrial tissue the endometrial tissue will also react to the hormones and so when you have period it will also react so let's take a closer look at what's going on so you here you have the left ovary the fallopian tube and the uterus here is the uterine cavity and the innermost layer the layer that react to the hormones and sheds is the endometrium here is endometrial tissue that are present outside the uterus and this is characteristic of endometriosis the pathophysiology is not fully known but there are a few theories out there and to put it simply therefore one is that it occurs due to retrograde administration or vascular lymphatic dissemination Kaleem ik metaplasia of multipotent cells or because of impaired immunity and we'll look more into each of these theories in the pathophysiology section later on but let's talk about the clinical presentation and usually endometriosis present in younger woman between 20 and 30 or 1314 and usually symptoms are bad heavy periods they can present with chronic fatigue also infertility is a common presentation not being able to conceive chronic pelvic pain is very common severe dysmenorrhea which is painful menstruation they can also have deep dyspareunia which is deep pain during sexual intercourse and also they can have symptoms of pain during defecation endometriosis should be considered in any patient really female patient with dysmenorrhea who are not responding with non-steroidal anti-inflammatory drugs it's good to remember the symptoms of endometriosis as the four DS and to remember it better let's draw a diagram looking at a sagittal section of the female pelvis so we're talking about the four DS the first D is dysmenorrhea which is essentially painful heavy bleeding dysuria which is pain urinating if there is ectopic individual tissues on the bladder for example there's this ki jiye which is pain discomfort upon defecation and this is usually if there's an ectopic endometrial tissue or on the bowel or the rectal area and the final D is this paeonia which is pain during sexual intercourse there are many differential diagnoses of endometriosis because there are many causes of chronic pelvic pain or you know painful bleeding we can we can divide these differential diagnoses into Dyna collage achill and non gynecological differential diagnosis let's look at McDonald collage achill first and these include adenomyosis which are endometrial glands found in the end in the myometrium and this will also react to hormones during each menstrual cycle another differential is leiomyoma which are essentially fibroids and they can cause similar symptoms then there is a pelvic inflammatory disease which is mainly caused by STI that it's very and it's a very common cause of chronic pelvic pain then you have uterine myoma as well as ovarian cysts both of which are common more so though very insist differential diagnosis of a non gynecological cause include irritable bowel syndrome inflammatory bowel disease and interstitial cystitis which is inflammation of the bladders instance in interstitial investigations to order for someone presenting with suspected endometriosis includes a full blood count and this is to check for any signs of infection anemia I'm also checking electra urea creatinine to check for kidney function then you can also perform an abdominal and transvaginal ultrasound which is actually very important and its first line and it's to see of any obvious anatomical changes in the be productive or non reproductive organs imaging such as an MRI and or CT scan can often help also detect abnormalities around the area and can also detect sometimes ectopic endometrial tissues finally there is a laparoscopy which is actually used to diagnose endometriosis and is the gold standard laparoscopy czar done under general anesthetics but it should be noted that even if a doctor suspects endometriosis it doesn't mean that the patient has to have a laparoscopy because the management will be the same regardless or a trial medication will happen regardless and so patients go on medications to see if it helps without having surgery without confirming the diagnosis of endometriosis although the exact mechanism of endometriosis is unknown there are some possibly known risk factors including a low birth weight early menarchy short menstrual cycle late menopause certain genes genetics and eating heaps of red meat is also a risk factor obesity and certain chemicals increase your chances of developing endometriosis but there are also protective factors and these include fruits vegetables having multiple pregnancies omega-3 oil as well as prolonged breastfeeding prolonged lactation so we touched on the pathophysiology of endometriosis briefly let's now take a closer look here is the brain and here is the female genital tract the female reproductive tract has blood supply of course the most inner layer of the uterus is the endometrium the layer which sheds during the period in the brain there is what's called the pituitary gland which is an endocrine gland that produces a hormone called luteinizing hormone in response to Vanetta trip and releasing hormone from the hypothalamus anyway luteinizing hormone or LH its role is to cause or induce ovulation so it targets the ovaries telling it to release an egg at day 14 of the female reproductive cycle so mid cycle the egg will then travel through the fallopian tube and will either be fertilized or not fertilized by the sperm let us say that there is no fertilization that there is no sperm and with no fertilization means that menstruation will occur in two weeks so this person will have a period in two weeks so during this time before the period the ovary is actually still producing estrogen and progesterone but by day 28 of the female reproductive cycle the east region and progesterone levels draw and with the drop of East region and progesterone this actually will somewhat allow for menstruation it will stimulate you can say administration and so the endometrial lining will shed and you get a period in endometriosis because you have endometrial tissues elsewhere outside the uterine cavity this ectopic endometrial tissue will also react to the drop in hormones and they will also shed you can say and this will cause really painful period dysmenorrhea if the ectopic endometrial tissue was on the bowel or the rectum it can cause this Kezia during periods endometriosis can also cause this perineum because of the sensitive genital tract and if the endometrial tissue is present on the bladder for example it's this ectopic tissues there it can close this urea just remember the four DS so how does the endometrial tissue actually end up outside the uterine cavity or the myometrium in the first place well one common theory is the that there's retrograde menstruation whereby during menstruation some of the endometrial tissue may have traveled backwards retrograde back along the fallopian tubes into the surrounding peritoneal cavity another theory is the vascular and lymphatic dissemination of the endometrial cells theory and here it's essentially thought that the endometrial tissues move via the vasculature or the lymphatic from the uterus and deposit elsewhere in the peritoneal cavity the third theory is based on the clinic metaplasia of multipotent cells in the peritoneal cavity here the ectopic endometrial tissue is thought to come from clinic epithelial cells that undergo what's called a metaplastic reaction or metaplasia so if I'm not mistaken basically the Ptolemaic cells develop into cells of the peritoneum and the surface of the ovary usually however here the clinic cells undergo metaplasia and it actually causes these cells to transform into individual cells but these cells are not present in the uterus rather they become present you know outside the uterus finally the fourth theory of endometriosis is an impairment of the immune immune system but I won't really go into this because I'm not really sure how that works so that was a pathophysiology now let's focus on the pathology of endometriosis and we can and it can be gross or microscopic depending on I guess the severity or the type of endometriosis and there are three pathological forms the first is just endo endometriosis within the ovary so it's an ovarian lesion here the ovarian cyst is formed by ectopic endometrial tissue this is known now as an endometrium ah the second pathological forms is is the superficial peritoneal lesion and typically this type is located on pelvic organs or pelvic peritoneum and it has a characteristic powder burn or gunshot lesion appearance the third pathological form is deep infiltrative endometriosis and this is a solid endometriosis mass situated greater than five millimeters deep under the peritoneal surface and this type more likely did not require some sort of sort of surgical intervention which brings us to the last part of the video which is management or second last pot so management includes symptomatic management which can which includes non-steroidal anti-inflammatory drugs but there's also hormonal treatment and the hormonal treatment the aim is essentially to mimic pregnancy to mimic menopause thereby preventing menstruation and there are many hormonal treatments let's see how they work here is the brain and the female reproductive tract the hypothalamus produces Granada trope in releasing hormone G and Rh which stimulates the pituitary to release luteinizing hormone LH when LH luteinizing hormone is high it will stimulate ovulation in the ovaries and as we know the eggs are released the egg is released early on after ovulation estrogen and progesterone are produced and this actually sends a negative feedback to the hypothalamus telling it to stop producing good at a trope and releasing hormone and because good at a trope and releasing hormone is inhibited everything stops some medication used to treat endometriosis works on different parts of this diagram so for example Granada trope in releasing hormone agonists is a drug that can be used for endometriosis and how this works is that by stimulating the negative and releasing hormone you are stimulating the production of estrogen and progesterone which will maintain the the endometrial lining and so you do not have periods then there's also the combined oral contraceptive pill basically estrogen and progesterone which means that you have more of these hormones which means that you will stop the the cycle essentially the menstrual cycle you stop menstruating then you have progestogen which is basically the hormone progesterone and it does the same thing it you know prevents or lowers the heavy bleeding in the reproductive cycle Mirena is another treatment which is where a device an umbrella looking device is placed inside the uterine cavity the Mirena releases hormones locally progesterone which then inhibits administration it is good because unlike the oral contraceptive pill the Mirena acts only locally and so does not actually have a systemic effect like the oral contraceptive pill the Mirena and all these other hormonal treatments are also very effective in thinning the lining of the endometrium and so you you do have a lighter period as well so we just talked about symptomatic treatment hormonal treatment and finally there is surgical treatment and the aim of the surgical treatment is to eliminate all visible peritoneal lesions endometrium is and to try to restore normal anatomy and there are three main surgical options there is laparoscopic ablation of ectopic endometrial tissues there is open surgery with local resection and there is hysterectomy plus - oof rectum II in serious cases one thing I have not added here is treatment of infertility as this is also common in people who have endometriosis finally it's important to talk about the complications of endometriosis which include mainly infertility development of adhesion because of inflammation or post surgery ovarian failure post operation people who have endometriosis also have an increased risk of autoimmune diseases or predisposition to autoimmune diseases as well as mental health

Channel: Armando Hasudungan

Views: 323,890

Rating: 4.9094987 out of 5

Keywords: Endometriosis, pelvic pain, chronic pelvic pain, gyaenocology, gyenocology, gynecologist, obstetrics and gyenocology, O and G disease, pathophysiology, pathogenesis, mechanism of disease, medicine, endometrioma, heavy menstrual bleeding, painful periods, menstrual cycle, pathology, What is endometriosis?, management, how to treat, signs and symptoms of endometriosis, endometrium, diagnosis, physiology, hysteroscopy, infertility

Id: EsSrUP3IvL8

Length: 18min 43sec (1123 seconds)

Published: Sun Jun 18 2017