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Types, Severity and Classification of endometriosis - adenomyosis

Endometriosis is more than 1 disease

Images of endometriosis : different diseases of different severity and different symptoms

Definitions
The endometrium is the tissue lining the inside of the uterus. The endometrium grows during the cycle and is shedded at menstruation.
Endometriosis : is by definition endometrial stroma and glands outside the uterus
Adenomyosis : endometrial stroma and glands in the myometrium of the uterus

Microscopy and activity of endometriosis.

microscopy of deep endometriosis gynecology endometriosis, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, menopause, images
deep endometriosis
microscopy showing activity of deep endometriosis gynecology, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
is very active

Subtle endometriosis is morphologically very active
Typical endometriosis are inactive burnt out lesions
Cystic ovarian endometriosis is inactive and contains hardly any endometriotic cells in the wall.
Deep lesions are morphologically very active

The activity of endometriosis is sometimes used as argument to consider subtle endometriosis as ‘severe’ since active

Clinical types of endometriosis

During laparoscopy endometriosis varies from tiny little endometriosis lesions to large chocolate cysts or invasive endometriosis nodules. Subtle, typical, cystic, and deep endometriosis are several diseases.

Subtle endometriosis : small superficial endometriosis

gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
white vesicle
Subtle endometriosism gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
polipoid lesion

Subtle endometriosis are believed to be the early stages after implantation. They are small lesions (1 to 3 mm) which macroscopically look like white vesicles, red vesicles, or flame like endometriosis.

Subtle endometriosis can hide more severe deep endometriosis and are often associated with typical endometriosis. In the example below, subtle endometriosis are shown covering a deep endometriotic lesion whereas a typical endometriosis is visible in the left uterosacral ligament.
Subtle lesion are not a pathology and occur in 80% of a normal population. Subtle endometriosis can present very atypically and even mimic an ovarian cancer as shown below right. Another frequent mistake is to diagnose ‘endosalpingiose’ as endometriosis

Subtle endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Subtle endometriosis image
Subtle endometriosis image
Subtle endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Subtle endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
endosalpingiosis
Subtle endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
red vesicle
Subtle endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
white vesicle
Subtle endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
white vesicle

Typical endometriosis : 0.5-4 cm superficial lesions

Typical endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
typical lesion bladder
Typical endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
diaphragma

Typical endometriosis are black puckered endometriosis generally in a white sclerotic area. They are 1 to 2 cm in diameter, or larger. These endometriosis are found in the pelvis and on the diaphragm.

Deep endometriosis often present as typical endometriosis.

Typical endometriosis can present atypically.

Often the mistake is made to consider subtle endometriosis as disease Koninckx et all described the endometriotic disease theory to dismiss subtle endometriosis as a pathology.

Typical endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Typical endometriosis image
Typical endometriosis image
Typical endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Typical endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Typical endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Typical endometriosis image gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Typical endometriosis imagem gynecology, endo;etriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images

Cystic ovarian endometriosis

Cystic ovarian endometriosis image gynecology, endometriosis laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy
Stripping of cyst
Cystic ovarian endometriosis image gynecology, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
can mimic ovarian cancer
Cystic ovarian endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images

Cystic ovarian endometriosis are Chocolate cysts the ovary. These cysts are mostly 3-4 cm in diameter but can grow as large as 15 cm.
These cyst usually form adhesions with the pelvic wall and the other organs of the pelvis.
As a therapy stripping of the wall is the preferred technique. Medical therapy is ineffective
A cystic corpus luteum can mimic a cystic ovarian endometriosis

Cystic ovarian endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
small cyst
Cystic ovarian endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
laser incision
Cystic ovarian endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
excision
Cystic ovarian endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
closure with glue

Deep endometriosis : solid tumors

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Recto-vaginal nodule
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
deep after surgery
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
before surgery

Endometriosis can present as solid tumours up to 5 by 6 cm in diameter most frequently in the pouch of Douglas.
From the left picture it is obvious that this endometriosis is in close proximity of the vaginal wall, causing dyspareunia, and of the rectum, causing pain during bowel movement.
Other localizations are the sigmoid (not detectable clinically and easily missed during laparoscopy (except when the surgeon has great experience)and between the uterus and the bladder (hence bladder irritation and pain.

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
diameter of nodules
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
only the bigger are felt
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
our surgeries

Images of Rectovaginal nodules : Type I II III

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
central nodule
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
bowel hides deep
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
normal rectoscopy
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
partial occlusion

Endometriosis can involve the vesico-uterine fold

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
vesico-uterine fold
DIE, Deep endometriosis image, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
DIE, Deep endometriosis image
blue spots at cystoscopy
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
hidden nodule

Endometriosis can involve the ureter and the vagina

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
ureter involvement
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
hydronefrosis
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
vaginally visible
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
after excision

Endometriosis can also be found at the level of the sigmoid : unless looked for this endometriosis are missed at laparoscopy since situated higher outside the pelvis, as shown on the left image

DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
sigmoid nodule
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
contrast enema to judge occlusion
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
50% occlusion
DIE, Deep endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
50% occlusion

The Ovarian remnant Syndrome : endometriosis

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The ovarian remnant syndrome is fortunately rare. The literature is almost empty and I have not seen more than ten over the last 15 years. Diagnosis and surgery always are difficult.
The ovarian remnant syndrome should be thought of when a women following hysterectomy and ovariectomy has severe chronic pain, whereas at ultrasound (or other imaging techniques, a multi-cystic ovary is found with a suspicion of endometriosis). At laparoscopy as depicted below, almost invariably a frozen pelvis with encapsulated ovary is found : at dissection after identification of the ureter, is becomes immediately clear that the ureter is located inside the ovarian mass. Therefore the surgeon should be very experienced.

Ovarian remnant endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Ovarian remnant endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
dissection
Ovarian remnant endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
shows ureter
Ovarian remnant endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
through the lesion
Ovarian remnant endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
after resection

Adenomyosis

adenomyosis endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Nl Junctional zone
adenomyosis endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Thickened Junctional zone
 laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
focal andenomyosis
adenomyosis endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Transmural adenomyose
 laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Transmural adenomyose
adenomyosis endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Ultrasound

There is a lot of confusion
The definition is clear: stroma and glands in the myometrium. This is however a diagnosis by pathology made after hysterectomy.
The prevalence varies between 30 and 70% according to the number of slides investigated .
The diagnosis can be also tentatively made with imaging as ultrasound or MRI. Two types can be diagnosed : junctional zone thickening and focal adenomyosis. The biggest problem is that often diagnosis is only 70% accurate.
Adenomyosis is believed to be a cause of pain and infertility with little evidence
Adenomyosis is often an alibi to do an hysterectomy in women with chronic pain since theoretically adenomyosis is difficult to exclude

Peritoneal Pockets or Allen en Master syndrome : endometriosis

allen and masters endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Allen en Masters
allen and masters endometriosis image laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, images
Allen en Masters
allen and masters endometriosis image
Allen en Masters
allen and masters endometriosis image
Allen en Masters endometriosis

Peritoneal pockets are an unclear pathology Pockets in the peritoneum. They can be large and deep. Peritoneal pockets are believed to be associated with endometriosis
Excision is believed to be the right therapy.

Haemorrhagic ascites Endometriosis

Haemorrhagic ascites endometriosis image

Endometriosis associated with haemorrhagic ascites is a rare condition. Can contain up to 6-10 litres and Is Believed to be similar to a Meigs syndrome


What is severe endometriosis - which classifications ??

History of classifications
1980 Acosta classification made a distinction between superficial and cystic ovarian endometriosis.
1985 AFS classification is a point scoring system. Essential I and II were superficial endometriosis, whereas III and IV cystic ovarian with adhesions.
1986 Subtle were described after this many women which beforehand were classified as ‘normal’ now became endometriotic.
1989 Deep was described

The definition of severe has become variable according to the authors
Severe = big endometriosis subtle are very small, typical generally small, cystic can be large cysts with a lot of adhesions, whereas deep can cause a lot of pain and are surgically the most challenging. Obviously a nodular lesion of 0.5 cm diameter and of 5 cm diameter is not the same.
severe = active endometriosis.By pathology subtle and deep are active endometriosis, whereas typical and cystic are generally inactive.
Severe=Surgically difficult

Classifications
the rAFS Classification is a surgical classification without subtle and deep The rAFS is the most widely used classification. It is a point scoring system for diameter of endometriosis and for adhesions. It is an old surgical classification. Deep endometriosis are not represented : a most severe deep lesion of 5 cm can be classified as I.Classes I and II are superficial endometriosis (thus subtle or typical) of respectively less or more than 3 cm in diameter.-classes III and IV represent cystic ovarian endometriosis with adhesions.
The Leuven - AFS classification. adds subtle and deep endometriosis to the rAFS

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