Table Of ContentAn Atlas of
ENDOMETRIOSIS
An Atlas of
ENDOMETRIOSIS
Third Edition
Edited by
Caroline Overton MBBS MD MRCOG
Consultant Gynaecologist, St Michael’s Hospital and
University of Bristol, UK
Colin Davis MD MRCOG
Consultant Obstetrician and Gynaecologist, Specialist, St Bartholomew’s Hospital
London, UK
Lindsay McMillan FRCOG
Consultant Gynaecologist, Portland Hospital
London, UK
Robert W Shaw CBE MD FRCOG
Immediate Past President of the World Endometriosis Society;
Head of Obstetrics and Gynaecology, University of Nottingham
Derby City General Hospital, and Head of School of Human Development,
University of Nottingham, UK
Foreword by
Charles Koh MD FACOG FRCOG
Reproductive Specialty Center,
Milwaukee, WI, USA
CRC Press
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Contents
Foreword vii
Preface ix
Acknowledgements xi
1 Aetiology 1
2 Basic science of endometriosis 5
3 Clinical features of endometriosis 9
4 Clinical findings 25
5 Classification and histological diagnosis 35
6 Ovarian endometriosis 45
7 Principles of treatment 51
8 Medical treatment of endometriosis 57
9 Surgical treatment of endometriosis 63
10 Ultrasound assessment of endometriosis 85
Bill Smith
11 Nutrition and endometriosis 105
Marilyn Glenville
Appendix 111
Index 113
Foreword
Endometriosis remains an enigma despite the many years Fortunately, an increasingly sophisticated understanding
elapsing since its description by Samson. It continues to defy of deep endometriosis is now present in centers that treat
research aimed at uncovering its etiology and the corre- rectovaginal endometriosis with complete excision of disease
sponding rational management that would result. Equally to clear margins. In addition to providing longer term relief,
perplexing is the fact that afflicted women do not suffer the such dissection also teaches the extent of such disease. In
same symptoms and in fact some are completely asympto- 2005–2006 alone there were nine papers on laparoscopic
matic. Research into the genomic characterisation of bowel resection for deep rectovaginal endometriosis, almost
endometriosis may hold the greatest promise yet, and per- as much as in the previous 10 years. A very welcome trend
haps variable expression may explain the variable affects of in such specialized centers is the emphasis on adequate
the disease. But even this approach will see many false leads removal of disease, rather than resorting to hysterectomy
before the etiology is finally elucidated. and castration, the latter in my opinion being an overzealous
In the meantime however, the great number of women surgical extrapolation of Samson’s theory. This approach is
suffering from endometriosis need effective treatment now, a tragedy for younger women.
and it is important for the gynecologist to be up to date in Hence to clinically understand endometriosis one must
their understanding of treatment algorithms so that maxi- astutely sift through literature and disqualify papers that
mumbenefit can accrue to patients, and just as importantly, though well designed, were conducted at a time when little
that harm is not done from ignorance or employment of was known of subtle and deep endometriosis. Only thus can
outmoded treatment. cumulative knowledge be garnered, leading ultimately to
The discerning student of endometriosis must fully precise clinical understanding of the disease and its treat-
understand the temporal evolution of knowledge when ment. How does one begin on this path? Exactly by reading
reviewing the literature and realize that much of the older this wonderfully crafted text – the Atlas of Endometriosis.
data may not be extrapolated. In this third edition the authors have significantly updated
For example, the recognition of the various morphological the content to reflect current understanding, management
appearances of endometriosis other than the classical ‘powder and controversies resident in the treatment of endometrio-
burn’, in particular the almost microscopic clear papule sis. The chapters are clearly written and will provide a basis
visible only by laparoscopic magnification, postdated earlier for the understanding of current practice in endometriosis
studies by laparotomy and unmagnified laparoscopy that treatment for the student, trainee and practitioner. For the
reported the histological presence of endometriosis in ‘normal’ basic science researcher, this atlas gives a much needed sum-
peritoneum. mary of clinical information that aids their understanding
‘Deep’ endometriosis was first defined in the early of the clinical disease, thus providing substantive underpin-
nineties, prior to which it was considered only ‘scar’ tissue ning to their research at increasingly molecular levels.
and therefore not necessary to treat. Hence studies on This is a very comprehensive and balanced publication
surgical treatment efficacy and recurrence before this with up to date coverage of the theoretical, basic science,
period should not, for example, be used in contemporary clinical, diagnostic and imaging, medical, surgical, and
meta-analyses. nutritional aspects related to endometriosis. It is more
vii
FOREWORD
substantive than being just an ‘atlas’, but certainly demon- The historical reflex of hysterectomy and oophorectomy as
strates the strengths of an excellent atlas by including a surrogate treatment of deep endometriosis is correctly
very comprehensive array of photographic examples of questioned in the light of excisional data, and offers women
surgical findings, imaging, histopathology and assisted hopeof symptom relief without sacrificing fertility.
reproductive technology. The authors are to be congratulated for producing this
Fertility treatment is brought up to date with contem- excellent atlas which is definitely recommended reading for
porary evidence based considerations of surgery versus the intended audience.
assisted reproduction in the context of success rates related I can think of no better volume for the gynecologist,
to disease severity. general surgeon, urologist, internist, family doctor to
Pain amelioration strategies similarly give weight to obtain a ‘fast forward’ to currency of their knowledge of
contemporary evidence of efficacy of excisional surgery by endometriosis from the last time they learnt it as medical
laparoscopy, adjunctive measures like presacral neurectomy students. This allows them to more productively share in
and the clear abandonment of procedures like LUNA. A the care of the patient as an effective ‘team’. This volume is
clear enunciation of medical treatment in augmenting the also recommended for the resident, medical student and
results of surgery is well discussed. nurse wishing to understand endometriosis.
The section on rectovaginal endometriosis excellently I thank the authors for the honor and privilege of writing
describes a once misunderstood and avoided area of this foreword and commend them for performing an out-
endometriosis surgery, which often resulted in prolonged standing service in the education of their readers on
poor quality of life because of inadequate treatment. The endometriosis.
authors’ attitude mirror the recent immense interest among
the foremost practitioners of radical endometriosis surgery Charles Koh MDFACOGFRCOG
in laparoscopically excising the disease completely, including Reproductive Specialty Center
bowel resection, urinary resection and repair if necessary. Milwaukee, WI, USA
viii
Preface
Endometriosis is arguably the most frequent problem The first Atlas of Endometriosiswas published in 1993 and
encountered in gynaecology. It affects women in their a second edition in 2002. A third edition is required to
reproductive years and has been described as second only update the atlas. Imaging, particularly magnetic resonance
to uterine fibroids as the most common reason for surgery and ultrasound imaging, have developed, and new images
in premenopausal women. The true incidence is unknown, are included. Advances in camera technology have result-
but the study that came closest to identifying the fre- ed in greater clarity of the laparoscopic images, and images
quency of the disease in the general population estimates are now placed throughout the text making the atlas easier
that6% of all premenopausal women have endometriosis. to read.
Endometriosis affects women in the reproductive years, is There have been significant contributions to the medical
associated with pelvic pain and infertility and, although not literature about existing medical treatments. A section has
life threatening, can seriously impair health. It has huge eco- been added on new and potential medical treatments, as
nomic and social consequences. The economic cost can be well as complementary therapies. A section has also been
calculated directly in terms of health care resources con- added on the natural progression of the disease, fertility
sumed, and indirectly in terms of lost work capacity. The cost and pregnancy. This remains the definitive Atlas of
of intangibles such as suffering and reduced quality of life Endometriosis, covering all aspects of the disease and every
is impossible to quantify. The estimated total annual cost to question asked by patients.
society for all women with pelvic pain was calculated in 1992
to be £158.4 million (direct) and £24 million (indirect). CO, CD, LM, RWS
ix
Acknowledgements
The authors would like to acknowledge the following Professor J Scott†, kindly supplied Figure 3.24.
contributions;
Dr Basil Shepstone, Consultant Radiologist at the John
Dr Heather Andrews, Consultant Radiologist at the Radcliffe Hospital, Oxford, kindly supplied Figures
Bristol Royal Infirmary, kindly supplied Figures 4.19–4.24.
4.18(a,b).
Mr Bill Smith, of Clinical Diagnostic Ultrasound
Mr David Bromham†, kindly supplied Figures 3.8 and Services, London, kindly supplied Chapter 10.
3.23–3.25.
Professor Chris Sutton, Professor of Gynaecological
Mr Alpesh Doshi, Chief Embryologist at the Assisted Surgery, University of Surrey, kindly suppled Figure 9.64.
Conception Unit, University College Hospital, London,
Figures 2.1, 5.1 and 5.10 are reproduced by courtesy
kindly supplied Figures 7.8–7.13.
of Fertility and Sterility and The American Society for
Dr Marilyn Glenville (www.marilynglenville.com) Reproductive Medicine.
kindly supplied Chapter 11.
Dr Joya Pawade, Consultant Histopathologist at the
Bristol Royal Infirmary, kindly supplied Figures
5.11–5.18, 7.14 and 7.15.
xi
CHAPTER 1
Aetiology
INTRODUCTION and biologically similar to normal endometrium. This ectopic
endometrial tissue responds to ovarian hormones undergoing
Endometriosis is one of the most common problems en-
cyclical changes similar to those seen in eutopic endo-
countered in gynaecology. It affects women in their repro-
metrium. The cyclical bleeding from endometriotic deposits
ductive years and has been described as second only to
appears to contribute to the induction of an inflammatory
uterine fibroids as the most common reason for surgery in
reaction and fibrous adhesion formation, and in the case of
premenopausal women1. Its true incidence is unknown,
deep ovarian implants, leads to the formation of endome-
but the study that came closest to identifying the frequency
triomas or chocolate cysts.
of the disease in the general population estimated that 6%
The symptoms of endometriosis are variable and may be
of all premenopausal women have endometriosis2.
unrelated to the extent of the disease. The most extensive
Endometriosis affects women in the reproductive years,
endometriosis can be asymptomatic and be discovered ac-
is associated with pelvic pain and infertility and, although
cidentally. Conversely, small lesions may produce marked
not life threatening, can seriously impair health. It has huge
symptoms. Pelvic pain related to the menstrual cycle, dys-
economic and social consequences. The economic cost can
menorrhoea and infertility are the major complaints of women
be calculated directly in terms of health care resources con-
with endometriosis, while menstrual irregularities and dys-
sumed, and indirectly in terms of lost work capacity. The
pareunia are also commonly associated with the disease.
cost of intangibles such as suffering and reduced quality of
The clinical diagnosis of endometriosis is primarily made
life, is impossible to quantify. The estimated total annual cost
at the time of laparoscopy, although there is increasing
to society for all women with pelvic pain was calculated to
support for empirical treatment with laparoscopy if symp-
be £158.4 million (direct) and £24 million (indirect). The
toms persist. The classic appearance is of blue-black lesions,
estimated total lifetime treatment costs for a 1-year inci-
but many subtler appearances are now recognised.
dence cohort of women with pelvic pain is £10.5 million
The term endometriosis was first used by Sampson in the
(direct) and £2.6 million (indirect)3.
1920s10,11. He and Meyer spent their medical careers argu-
Endometriosis affects 45–70% of adolescents with chron-
ing their theories of pathophysiology. More than 80 years have
ic pelvic pain4. In a large survey of over 70000 adolescent
passed, but endometriosis remains a perplexing and poorly
women, dysmenorrhoea was a common cause of reported
understood disease.
school absence5. In the United States, chronic pelvic pain
affects approximately one in seven women, with very high
EPIDEMIOLOGY
associated annual health costs6. A Norwegian study dem-
onstrated that 2% of women had been treated for this con- Endometriosis is primarily a disease of the reproductive
dition by the age of 407. Endometriosis-associated pain may years, and is only rarely described in adolescents (when it is
be found in up to 60% of women with dysmenorrhoea and associated with obstructing genital tract abnormalities) and
40–50% of women with pelvic pain and dyspareunia8. postmenopausal women (when it is associated with obesity
Despite the identification of symptoms there is often a and exogenous hormones). No differences in the incidence
delay in establishing a diagnosis of endometriosis and hence of the disease between races have been found except for
a delay in ensuring effective treatment. This delay is on Japanese women, who have been reported to have twice the
average between 6 and 7 years, and a consistent feature of incidence of Caucasian women12.
most female populations9. The exact prevalence of endometriosis in the general
Endometriosis is characterised by the presence, outside female population is unknown. Diagnosis depends on the
the endometrial cavity, of tissue that is morphologically observation of implants, at the time of either laparoscopy
1
AN ATLAS OF ENDOMETRIOSIS
Table 1.1 Prevalence of endometriosis by presentation elsewhere, it should occur with increasing frequency with
advancing age. The clinical pattern of endometriosis is
Women undergoing tubal sterilisation6 2%
distinctly different, with an abrupt halt in the disease at
Women with affected first-degree relatives7 7%
Infertile women8 15–25% the cessation of menstruation.
Women with surgically removed ovaries9 17%
At diagnostic laparoscopy10 0–53% Menstrual regurgitation and implantation
At gynaecologic laparoscopy10 0.1–50%
The most popular theory is that proposed by Sampson in
Unexplained infertility8 70–80%
1921. He postulated that fragments of the uterine endo-
metrium, transported through the fallopian tubes in a
retrograde manner at the time of menstruation, implant in
or laparotomy (Table 1.1), and until a simple screening test the peritoneal cavity, giving rise to endometriosis10.
is developed, the true incidence will remain unknown. The following evidence exists to support the theory of ret-
There has been only one population-based study, which rograde menstruation being the prime mechanism for the
showed a prevalence of 6.2% for the disease2. Most preva- development of endometriosis: viable endometrial cells
lence studies have reported women presenting with one of have been demonstrated in menstrual effluent15 and have
several symptoms justifying laparoscopy, e.g. pelvic pain, been grown in vitro16and even within the peritoneal cavity
dysmenorrhoea and infertility. (in monkeys) if the menstrual flow is diverted to permit
Delayed childbearing, either by choice or due to infertil- intraperitoneal menstruation17. Endometrial cells obtained
ity, has been implicated as a risk factor for the development from the menstrual effluent have been demonstrated to be
of endometriosis. The risk of developing the disease corre- transplantable to abdominal wall fascia18. The tubal ostia
sponds with the cumulative menstruation (menstrual are located near the uterosacral ligaments in the pouch
frequency and volume over time)13. Women with shorter of Douglas, which are one of the most common sites of
menstrual cycles (fewer than 27 days) and longer duration endometrial cell implantation19.
of flow (more than 7 days) are twice as likely to develop Several studies have confirmed a high incidence of retro-
endometriosis than those with longer cycles and shorter flow. grade menstruation (90–99%) and the presence of endome-
trial cells in peritoneal fluid in women of reproductive age,
PATHOGENESIS and yet, only 1–6% of these women have endometrio-
The precise aetiology of endometriosis still remains unknown. sis20,21. This suggests that retrograde menstruation alone does
It has often been called the disease of theories, because of not give rise to endometriosis, but that some other factor(s)
the many postulated theories to explain its pathogenesis. must be involved in its development. Those factors could
The major theories of causation of endometriosis are the include some alteration in the uterine endometrium of
metaplasia of coelomic epithelium14or the implantation of women with endometriosis, an altered immune response to
endometrial fragments which reach the pelvic cavity by retrograde menstruation or, alternatively, a more favourable
retrograde menstruation10. peritoneal environment that may stimulate the growth and
implantation of ectopic endometrium in the peritoneal cavity.
Transformation of coelomic epithelium
Dr Robert Meyer postulated the theory of coelomic meta- Genetic and immunological factors
plasia in 191914. He proposed that endometriosis develops Several clinical studies indicate that there may be a genetic
from metaplasia of cells lining the pelvic peritoneum. This factor related to endometriosis. The disease is more preva-
theory is based on embryological studies demonstrating lent in certain families; the risk of developing endometrio-
that Müllerian ducts, germinal epithelium of the ovary and sis is seven times higher and more likely to be severe in
pelvic peritoneum are all derived from the epithelium of women with an affected first-degree relative22,23. Endo-
the coelomic wall. If this theory is correct, peritoneum metriosis is more common in monozygotic than in dizygotic
must contain either undifferentiated cells capable of trans- twin sisters, but no association was found with particular
formation into endometrial cells, or differentiated cells that human leukocyte antigen (HLA) tissue types24.
maintain the capacity for further differentiation. The rare Dmowski and colleagues25 suggested that genetic and
case reports of endometriosis in men are taken as evidence immunological factors may alter the susceptibility of a woman
for the theory of coelomic metaplasia. However, if the to allow her to develop endometriosis. They demonstrated
theory is correct, metaplasia should occur wherever coelom- a decreased cellular immunity to endometriotic tissue in
ic membranes are present. Although there is embryological women with endometriosis. No clinically significant immune
evidence that the coelomic membranes cover the abdominal system abnormalities have been observed in women with
and thoracic cavities, endometriosis is rare outside the endometriosis, and there are no differences in individual
pelvis. Lastly, if coelomic metaplasia is similar to metaplasia subsets of circulating lymphocyte populations26.
2
