A Case Report on Deep Infiltrating Endometriosis- Endometrioma

Abstract

Endometriosis a progressive debilitating and estrogen dependent disease is the presence of endometrial tissue (glands and stroma) outside the uterus affecting general mental and social well-being of women¹. In recent times, changing lifestyles, increased awareness and better diagnostic modalities have led to an increase in the incidence of endometriosis. In reproductive age group, endometriosis affects 7 -10% of women and 8-10% of women who are infertile or present with pain abdomen. Also last three decades have seen a significant increase in research related to endometriosis.

Endometriotic tissue most commonly implants in pelvic viscera and peritoneum, less commonly involves cervix, hernial sac, umbilicus, laparotomy or episiotomy scars². No mutations are known to cause endometriosis so far. No mendelian pattern of inheritance seen but a multi factorial inheritance is suggested. Daniel Shroen in 17^th century first described the disease but definitive cause not known so far with poorly understood pathogenesis and limited therapeutic options which are effective. Various theories ranging from transplantation, metaplasia theory to various genetic  and immunologic factors have been proposed. To explain occurrence of endometriosis in cul-de-sac, mainly the Mullerian remnant theory, suggesting that atypical migration or differentiation of these remnants could imitate endometriotic tissue in posterior pelvic floor³.

Endometriotic lesions have a variable appearance⁴, typically ranging from superficial red lesions to white to black, dark brown or bluish puckered lesions to atypical yellowish discolorations in peritoneum, can present as subovarian adhesions or endometriomas in ovaries. Women with endometriosis can present with severe dysmennorhoea, dyspareunia, chronic pelvic pain, infertility, painful defecation, premenstrual pain or bleed, ovulation pain etc. and pelvic tenderness, a fixed retroverted uterus, tender utero-sacral ligaments, enlarged ovaries, visible lesions on vagina or cervix on examination (detection improved during menstruation)⁵.

 The modalities to diagnose endometriosis can very from physical examination, MRI, with TVS playing a very little role and the gold standard is laparoscopy followed by histological examination. Doppler improves the diagnostic accuracy (pericystic flow with resistive index more than 0.45 indicating low resistance waveform).CA 125 has a low sensitivity so not used for screening.

Keywords: Estrogen dependent disease; Dysmmenorrhoea; Infertility; Endometriosis; Endometrioma/Chocolate cyst.