9.       Endometriosis.       

You can guarantee that there will be a question on the subject.

Endometriosis is an enigmatic condition. 

What causes it? 

Why can a patient have massive pelvic endometriosis and no symptoms, yet a patient with one or two tiny spots can have her life made a misery? 

How do you get spots in remote places like the pleural cavity? 

Why can you eliminate all signs of the disease with drug therapy and not improve her fertility?

Classically it causes dysmenorrhoea, particularly pain that starts days before the onset of bleeding. 

Cramping pain that starts with the  bleeding is typical of spasmodic dysmenorrhoea caused by the uterus contracting (such contractions can mimic labour in the pressure generated). 

Deep dyspareunia is also a feature. 

Other features can be chocolate cysts of the ovaries (collections of old blood) and fixed retroversion of the uterus. 

Rarely you can have bowel symptoms. 

I have seen bowel obstruction from scarring caused by spots of endometriosis on the bowel wall. 

Remote deposits can occur: in the pleura, umbilicus etc.

I love the idea of Sampson the Obstetrician! 

The imagination leaps to overdrive.

Imagine him approaching the labouring woman with a pair of obstetric forceps and telling her his name.

(Sadly, he was more gynaecologist than obstetrician.)

His theory, which remains the main one, was that retrograde menstruation introduced viable endometrial cells into the peritoneal cavity.

These flourished under the influence of the hormones of the menstrual cycle.

They produced cyclical bleeding, causing the tiny accumulations of blood so typical of endometriotic spots.

And even the huge “chocolate” cysts of the ovaries, with large volumes of old blood.

If you want to know more about him, there is a good biography here:

http://www.urologiaaldia.com.ve/lecturas_recomendadas/PDF/2007/Historiadelapatologiaginecologica.pdf.

Other theories include origin from the peritoneum itself and immunology plays a part.

(The DRCOG exam MCQ database has a question about immunology & endometriosis.)

Some research has shown differences in cells from the endometrium and those from endometriotic spots.

Any surgery that exposes the endometrium can leave microscopic deposits in the operation field and result in endometriosis.

E.g. opening the uterus to remove fibroids. 

This supports Sampson’s theory.

The uterus has to be in some position – anteverted, upright or retroverted. 

This makes little difference. Retroversion is dealt with in MCQ 6, question 5. 

If the uterus is fixed in retroversion, something must be acting as the glue – usually adhesions from surgery, infection or endometriosis. 

Occasionally it may be malignancy.

Endometriosis is classically a condition of women in their 30s and 40s, but can be seen at any age.

Thickening of the utero-sacral ligaments is a classical feature and you can sometimes detect this clinically. 

It may be a source of dyspareunia. 

Because of the involvement of the pouch of  Douglas and the fact that the ovaries may be stuck there, the dyspareunia is of the deep variety. 

If the ovaries are adherent in the pouch of Douglas and “in the line of fire” during hanky-panky, the pain can be severe. 

Chaps will sympathise when told that this equates to having their testicles whacked.

Tubal involvement tends to be late and the result of adhesions, though you occasionally see endometriotic deposits on the tubes. 

The ovaries and pouch of Douglas are the main sites for deposits. 

Drug treatment may hold back the progression of the disease, but does not improve fertility, even if there is evidence of regression of the amount of the disease. 

Surgery, e.g. laparoscopic excision and laser treatment of endometriotic cysts of the ovaries may improve fertility, but this is still a source of debate.