Most common symptom of endometriosis is:

Ans: d (dysmenorrhea) Ref: Shaw, 13th ed, p. 442Dysmenorrhoea is the most common symptom of endometriosis. The pain begins before the onset of menstruation builds continuously until the flow the begins and thereafter gradually declinesEndometriosis- Def: Presence of functioning endometrium (glands + stroma) in sites other than uterine mucosa.Theories of endometriosis1. Coelomic metaplasia (Mayer and Ivanoff)2. Retrograde menstruation (Sampson's theory) (Implantation theory)3. Lymphatic theory (Halban) (Metastatic)4. Direct implantation5. Histogenesis by induction (Merrill)6. Hematogenous spread7. Hereditary factor8. Immunological factor9. Activation of embryonic cell nest10. Activation of wolfian rest11. Metaplasia of urotheliumSitesAbdominalExtra abdominal- Ovary- Pouch of Douglas- Uterosacral lig- Broad ligament- Recto vaginal septum- Rectum- Pelvic lymphnode- Rare site - Gut, ureter, urinary bladder appendix- Scar of hysterectomy- Caesarean scar- Tubectomy scar- Myomectomy scar- Umbilicus- Episiotomy scar- Vagina- CervixRare sitesPleura, lungs, deep tissues of arm and thighsChocolate cyst (endometrial cyst)Lining - usually columnarBelow epithelium - Pseudoxanthoma cells (hemosiderin deposition)Classic symptoms complexPelvic examinationDysmenorrhoea (commonest)MenorrhagiaDyspareuniaInfertilityBladder and bowel symptomsOther symptoms - pelvic pain, abdominal painAsymptomatic - 25-30%Bluish spots in post fornixPelvic tendernessNodules in pouch of DouglasCobble stone feel of utero-sacral ligamentFixed retroverted uterusBilateral adnexial massInvestigation of choice - Laparoscopy'Powder burns' lesions seen on - uterosacral lig'Match stick spots' seen on peritoneum of PODOther peritoneal lesions:Red flame shaped areasWhite patchesPeritoneal windowsSubovarian adhesionsSerum marker - Ca 125ManagementDrugsDoseMechanismProgestogensOral Medroxyprogesteroneacetate10 mg thrice daily x 6-9 months DydrogesteroneNorethisterone10-20 mg daily x 6-9 months10-30 mg daily x 6-9 monthsPseudopregnancyIM Medroxyprogesterone100 mg 2 weekly interval x 4200 mg every months x 4 Danazol400-800 mg orally in 4 divided doses x 6-9 monthsPseudomenopauseGestrinone2.5-5 mg orally twice a week x 6-9 monthsPseudomenopauseGnRH analoguesBuserelin 400 |ig intranasally thrice daily x 6 monthsNaferelin 200 (ig intranasally twice daily x 6 monthsGoserelin 3.6 mg depot monthly x 6 monthsMedical castration(b) Laparoscopy- Aspiration of peritoneal fluid- Destruction of endometriotic implant (<3 cm)- Chocolate cyst excision- Laparoscopic breaking of adhesion- LUNA (Laparoscopic uterosacral nerve ablation)(c) LaparotomyNotesPrevalence of endometriosis -10%Prevalence in infertile women - 30-40%Commonest site of endometriosis - Ovary2nd commonest site of endometriosis - Pouch of Douglas