Microscopy and activity of endometriosis.
Subtle endometriosis is morphologically very active
Typical endometriosis are inactive burnt out lesions
Cystic ovarian endometriosis is inactive with little endometriosis cells in the wall.
Deep lesions are superficially inactive but morphologically active when deeper than 5mm
The activity of endometriosis is sometimes used as argument to consider subtle endometriosis as ‘severe’ since active
Clinical types of endometriosis
Subtle: small superficial endometriosis
In 1986 non pigmented lesions were recognized as endometriosis, subtle lesions. They were believed to be early stages. They are small (1 to 3 mm) and look like white or red vesicles, polypoid or flame-like endometriosis.
Subtle endometriosis occurs together with other lesions and can hide more severe deep endometriosis. In the image below, subtle endometriosis covers a deep endometriosis lesion whereas typical endometriosis is visible in the left uterosacral ligament.
Subtle lesions are very frequent and occur in up to 80% of a normal population. Subtle endometriosis can be atypical and even mimic ovarian cancer as shown below right. A frequent mistake is to misdiagnose ‘endosalpingiosis’. Recently our understanding was updated by understanding the progesterone resistance.
Typical endometriosis : 0.5-4 cm superficial lesions
Typical endometriosis or gunshot lesions are 1 to 2 cm or larger black puckered endometriosis in a white sclerotic area. These endometriosis are found in the pelvis and on the diaphragm.
Deep endometriosis can present as typical endometriosis.
Cystic ovarian endometriosis
Cystic ovarian endometriosis or chocolate cysts the ovary, are mostly 3-6 cm in diameter but can be much larger or smaller.
These cyst usually are fixed to the pelvic wall and other organs of the pelvis.
Stripping of the wall is the preferred technique since less recurrences. However, more recently superficial treatment was reconsidered see our recent publication Medical therapy is ineffective
A cystic corpus luteum can mimic a cystic ovarian endometriosis
Deep endometriosis : solid tumors
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.
Deep endometriosis of the rectovaginal septum
rectoscopy is generally normal ; only the larger ones are felt
Deep endometriosis of the sigmoid
is easily missed during laparoscopy and is generally underestimated ; it is difficult surgery.
Fot this reason we think that a contrast enema remains the only reliable method to judge occlusion
The definition is clear: endometrial stroma and glands in the myometrium. The prevalence varies between 30 and 70% according to the number of microscopical slides investigated .
There are 3 types of adenomyosis
- thickening of the junctional zone
- diffuse adenomyosis
- nodular adenomyosis
Adenomyosis is a cause of pain and infertility
The Ovarian remnant Syndrome : endometriosis
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.
Peritoneal Pockets - Allen en Master syndrome
The pathophysiology of peritoneal pockets is unclear but pockets are strongly associated with endometriosis.
The endometriosis can be different (spiders) and pockets were considered Müllerianosis
Haemorrhagic ascites Endometriosis
Endometriosis associated with haemorrhagic ascites is a rare condition and the abdomen can contain 6-10 litres. We believe as published the mechanism is similar to a Meighs syndrome 2008_ussia_ascites
Severity of endo
Ask what your doctor means with severe
- Difficult surgery : deep endometriosis > cystic ovarian endometriosis >> typical endometriosis
- Often it means rAFS classes III and IV. However, when introduced deep endometriosis was not yet discovered, and deep lesions
- 1980 Acosta classification made a distinction between superficial and cystic ovarian endometriosis. Then Kistner which is similar
- 1985 rAFS classification is a point scoring system. Classes I and II were superficial endometriosis, whereas III and IV cystic ovarian with adhesions, as we described in 1991
- 1986 Subtle lesions were described: after this many women which beforehand were classified as ‘normal’ now had endometriosis.
- 1990 we described deep endometriosis
- 2011 we published a review, which recently was translated into the ENZIAN classification and the new AAGL classification