Ans. a (Endometriosis). (Ref. Williams, Obstertrics, 21st ed., 930)ENDOMETRIOSISDefinition# Occurrence of ectopic endometrial tissues outside the true cavity of uterus.Etiology# Samson's implantation theory attributed to reflux of menstrual endometrium through tubes.# Coelomic metaplasia theory.# Metastatic theory.# Histogenesis by induction.# Hormonal influence: mainly estrogen.# Common among woman in child bearing age, especially belonging to affluent class.The commonest sites# Are the ovary 55%, posterior broad ligament 35%, anterior and posterior pouch of Douglas 34% and uterosacral ligaments 28%.Clinical features# Pain is usually associated with menstruation or may occur immediately premenstrually.# Dyspareunia is common. It does not cause postmenopausal bleeding.# There may rarely be rupture or torsion of an endometrioma, irregular menses or cyclical problems with rectal bleeding, tenesmus, diarrhea, constipation, haemoptysis, dysuria, ureteric colic or scar pains.# The chance of conception may be as low as half that of the normal population (infertility).Investigations# Laproscopy is the best diagnostic measure.# Laparoscopically, endometriosis may appear white or red (active lesions), black/brown 'Powder9 burns or burn matchstick like lesions or white plaques of old collagen.# There may also be circular defects in the peritoneum (peritoneal windows/Allemmaster syndrome) or endometriomas with 'chocolate' fluid containing debris from cyclical menstruation.# Chocolate cysts of ovaries represents the most important manifestation of endometriosis.Medical treatment# Drugs are not indicated for the RX of asymptomatic, minimal endometriosis in patients wishing to conceive.# Recurrence after treatment is common.# All therapies suppress ovulation, thus conception is unlikely with good compliance.# For symptomatic endometriosis, continuous progestogen therapy, e.g., medroxyprogesterone acetate 10 mg TID for 90 days is most cost effective, has fewer side-effects and is more suitable for long-term use compared with more expensive alternatives. It acts by producing a state of pseudo-pregnancy, which ultimately leads to regression of the disease .# Another very cost effective alternative suitable for long term use is the continuous low-dose OCpills.# Second line drugs (alternative therapy) are the GnRH analogues, which can be administrated by nasal spray or implants (e.g., nafarelin, buseralin, goseralin, leuproelin), and the danazol 200 mg OD-TID.# Danazol is mildly anabolic, androgenic, anti-estrogenic and anti-progestational drug which acts by inhibiting pituitary gonadotropins (AIIMS-93). It causes pseudomenopause.# Its side effects are atrophy of the breasts, weight gain, hirsutism, excessive sweating, depression, & vaginitis# Conservative treatment: This may be carried out at laproscopy or laprotomy and includes diathermy destruction or laser vaporization of endometriosis deposits. Adhesions may be divided. It is also possible to enucleate or excise endometriomas.# Advantages of laser therapy in treatment of endometriosis are:- Precise tissue destruction- Minimum damage to surrounding tissues.- Relatively bloodless field- Promotes tissue healing without adhesion formation.Surgical treatment# Radical surgery (BSO +/- TAH) This may be indicated for those in whom fertility is no longer required. HRT may lead to a recurrence of endometriosis.