A 35-year-okl woman presents with primary infertility and palpable pelvic mass. Her CA-125 level is 90 U/ml. Diagnosis is:
Ans. b. Endometrioma Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. An endometrioma may be associated with symptoms of endometriosis (eg, pelvic pain, dysmenorrhea, and dyspareunia) or identified at the time of evaluation for a pelvic mass or infertility. Ovarian endometrioma is a benign condition, associated with raised CA-I25."Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. Thev typically contain thick brown tar-like fluid (hence the name "chocolate cyst") and are often densely adherent to surrounding structures, such as the peritoneum. fallopian tubes, and bowel. An endometrioma may be associated with symptoms of endometriosis (eg. pelvic pain, dysmenorrhea, and dyspareunia) or identified at the time of evaluation for a pelvic mass or infertility. A woman with a ruptured endometrioma may initially present with peritoneal signs and symptoms, elevated white blood cell count, and low grade fever, similar to patients with acute pelvic inflammatory disease or appendicitis. ""Ovarian endometrioma is a benign condition, associated with raised CA-I25. "Conditions Associated with Raised CA-125Neoplastic conditions GynecologicalNon-gynecologicalBenign conditions* Ovarian carcinoma (nonmucinous)* Endometrial carcinoma* Tubal carcinoma* CAIung* CA breast* CA pancreas* CA colon* Endometriosis* PID* Tuberculosis* Leiomyoma* Pregnancy* Menstruation* Hemorrhagic ovarian cysts* Liver diseaseLower abdominal pain and dysmenorrhea with chocolate cyst (Ovarian endometriosis) with blue-grey tattooing of the cyst is seen in given laparoscopic examination picture. This is highly suggestive of endometriosis."Chocolate Cyst: it is caused by endometriosis, and formed when a tiny patch of endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wail) bleeds, sloughs off, becomes transplanted, and grows and enlarges inside the ovaries, As the blood builds up over months and years, it turns brown. When it ruptures, the material spills over into the pelvis and onto the surface of the uterus, bladder, bowel, and the corresponding spaces in between. ""The diagnosis of ovarian endometriosis is facilitated by careful inspection of all sides of both ovaries, which may be difficult when adhesions are present in more advanced stages of disease. With superficial ovarian endometriosis, lesions can be both typical and subtle. Larger ovarian endometriotic cysts (endometrioma) are usually located on the anterior surface of the ovary and are associated with retraction, pigmentation, and adhesions to the posterior peritoneum. These ovarian endometriotic cysts often contain a thick, viscous dark brown fluid ("uchocolate fluid") composed of hemosiderin derived from previous intraovarian hemorrhage. "-- Novak s 13/e p388EndometriosisPresence of ectopic functional endometrial tissue is known as endometriosis. They contain both gland & stroma and espond to hormonal stimulation.Prevalence in general population: 10%QPrevalence among infertile couple: 30-40% QTheories:Implantation theory by SampsonCoelomic metaplasia (Meyer & Ivanoff)Direct implantationMetastatic theory: Halban's theory of metastasis through vascular or lymphatic channelHistogenesis by inductionSites:Ovary, Pouch of Douglas, uterosacral ligament, broad ligament, peritoneum of bladder, sigmoid colon, intestinal coil.Pathology:Endometriotic implants - Estrogen influence - Proliferation - No secretory change, shedding of blood - Cystic structure due to pent up secretions - Fibrosis due to blood Q.Powder Burn Appearance Q: Appearance of endometriotic implant is dark red, bluish or black cystic puckering due to fibrosis, small black dot QThe ovary have endometriotic cyst of varying size, bluish thickening of tunica albuginea Q. The epithelial lining of cyst is columnar, adjacent to epithelium is a layer of large, polyhedral, Phagocytic cell laden with blood pigment hemosiderin, also known as Pseudoxanthoma cells Q.Clinical FeatureDysmenorrhea, Pain, Infertility, Menstrual irregularity QDyspareunia (specially w hen present in pouch of Douglas) QPelvic Examination: Tenderness, nodule in POD. cobble stone feel Q of uterosacral ligament, fixed retroverted uterus: bluish or blakish puckered spot in posterior fornix.Diagnosis:Laparoscopy is gold standard for diagnosis of endometriosis Q.Powder burn or matchstick spots axe seen on laparoscopy Q.Laparoscopic FindingsUnless disease is visible in the vagina or elsewhere, laparoscopy is the standard technique for visual inspection of pelvis and establishment of a definitive diagnosis QCharacteristic findings include typical "Powder burn or gun sho" lesions on the serosal surface of peritoneum Q.In the presence of ovarian endometrioma >3 cm in diameter and deeply infiltrative disease, histology should be obtained to identify endometriosis and to exclude rare instance of malignancy .CA-125 >35 U/mL may be used as evidence of recurrence Q.Complications:Malignancy: MC type is endometroid adenocarcinoma QInfertility QUreteric obstruction & hydronephrosisTreatment of EndometriosisMedicalSurgical* NSAIDs in patients with pelvic pain, if the diagnosis of endometriosis has not been definitively (excision & biopsy) established.* Achieve an anovulatory state by hormonal contraception: Progestins (Medroxyprogesterone acetate), danazot, gestrinone, or GnRH* GnRH can be combined with estrogen & progestogen without loss of efficacy but with fewer hypoestrogenic symptoms.* Laparoscopic surgical approaches include excision of ovarian adhesions & of endometriomas Q.* Endometriomas: Excision is considered to be far superior in terms of permanent removal of the disease & pain relief* Operative laparoscopic surgery can provide pain relief & improved fertility.* Radical surgical options could include singular or bilateral oophorectomy.
Ovarian cancer
Endometrioma
Tuberculosis
Borderline ovarian tumor
Ovary