00:01
Our topic now brings
us to endometriosis.
00:04
Before I move on though,
I need to make sure that
we’re very clear about
the different terms
that look quite similar
with endometriosis that
you’d be responsible for
and I’ll be going
over all of these.
00:16
Here, endometriosis which
you're quite familiar with
the ectopic implantation of the
endometrium and different organs.
00:22
I’ll come to their definition again
but you know what I’m referring to.
00:26
If by chance you find ectopic
implantation in the ovary,
which is the most common site
of ectopic implantation.
00:33
Where should the
endometrium be normally?
The uterus.
00:38
If there’s endometrial
tissue on the ovary
guess what you call
that condition?
Let me ask you something
before we begin.
00:46
Is this a cancer, endometriosis?
No.
00:50
It’s not.
00:51
It’s an ectopic implantation.
00:53
Someone even argued that this is a
choristoma or heterotopic rest.
00:57
Whatever.
00:59
That’s really not my point.
01:00
That's neither here or there.
01:02
Really the point is
it’s not a cancer.
01:05
Why am I bringing this up?
Because if the most common site of
ectopic implantation is on the ovary,
you call this an endometrioma.
01:14
Doesn’t that awfully
sound like a tumor?
Wouldn’t you perhaps think
that it’s a cancer?
Sure. But it’s not.
01:22
So an ectopic implantation
of endometrium,
specifically on the ovary,
is called an endometrioma.
01:29
Two that sound alike.
01:31
A third one,
let’s say that you actually
have an ovarian tumor.
01:36
You remember what that’s called
that has a term endo in it?
At some point, we’ll get
into ovarian tumors.
01:42
We will be discussing
endometrioid tumor.
01:46
Clear?
Three.
01:48
What were they again?
Endometriosis, endometrioma,
endometrioid.
01:52
What if there was an inflammatory
process in the endometrium?
You call that endometritis.
01:58
Are we clear?
If not, that’s okay.
02:01
Let me at least introduce
these four terms to you
and we will wall
through each one.
02:05
So what is endometriosis?
It’s ectopic implantation
of your endometrium
on different locations
outside the uterus,
usually pelvic.
02:14
The most common site
will be the ovaries.
02:17
Now, imagine this now.
02:19
Is this ectopic implantation?
Is it like normal endometrium?
Meaning to say does it respond
like normal endometrium?
Yes, it does.
02:28
What is the hormone
that’s responsible
for proliferation
of the endometrium?
Good. Estrogen.
02:34
So here, you have
ectopic implantation
of the endometrium on the ovary.
02:39
You think its possible that it might
actually proliferate on the ovary?
Sure it can.
02:44
And you’re saying that there might
be menses on top of the ovaries?
That’s exactly what
I’m telling you.
02:50
What do you call this?
A chocolate cyst
Let’s move on.
02:53
The uterine ligament,
rectovaginal septum.
02:57
Look at this, look
where you are.
02:59
In the rectum!
You have endometrial
tissue in the rectum?
So that means that --
Oh, my goodness, as uncomfortable
as this is, listen,
there’s going to be, during
your menstrual cycle,
proliferation of the endometrial
in the rectal pouch.
03:16
Every time she has her
menstrual cycle, guess what?
She’s having a hard
time defecating.
03:23
It literally causes obstruction.
03:26
Where’s the most
common site though?
Ovaries and pelvic peritoneum.
03:31
Amazing!
You’ll find this
to be interesting.
03:34
When you have ectopic
implantation of the endometrium
on the pelvic peritoneum,
you actually call this what’s
known as coelomic metaplasia.
03:44
Let’s continue.
03:46
If you find
ectopic implantation of your
endometrium in your myometrium –
“Dr. Raj, you’re
really confusing me.”
Listen,
think uterus,
the inner lining is
called the endometrium.
04:03
What’s the muscle layer called?
Myometrium.
04:05
Myometrium.
04:07
Same concept as the heart.
04:09
Endocarditis or endocardium.
04:12
Myocardium.
04:13
Here, we have endoemetrium
and myometrium. Clear?
May I ask you something, should
you find the glandular structure
in a muscle layer of an organ?
I’m sorry, but it’s called
myometrium on purpose.
04:28
Myo- means muscle.
04:30
You should have smooth muscle
only in the myometrium,
very little glandular
structure if at all,
responsible for contraction.
04:40
But what if you find
glandular structure
from the endometrium,
in the myometrium?
What is it called when you
find something glandular
in an organ pathologically?
Adeno –
There we go.
04:55
I love this name.
04:56
Adeno- means glandular.
Myo- means muscle.
04:59
So you’re going to find a
glandular endometrial tissue
inside your myometrium.
05:03
Welcome to adenomyosis.
05:06
Adenomyosis is the presence of
endometrial gland in the uterine wall.
05:09
Period.
05:11
The uterine enlargement,
and bleeding if extensive,
and to the point where --
now we get to a topic
of what’s called –
Well, tell me about this
bleeding that the patient is --
if she’s having her menses,
do you think, you know --
Do you think it’s painless?
Are you kidding me?
This is absolutely painful.
05:30
What is the medical term
for painful menses?
Dysmenorrhea.
05:35
And specifically, secondary dysmenorrhea.
05:39
We have now completed
our discussion of all three
major secondary dysmenorrheas.
05:49
Number one, fibroids, leiomyoma.
05:52
Let me stop there.
05:52
You think about leiomyomas.
05:56
Next, endometriosis.
05:58
Thirdly, adenomyosis.
06:00
All cause painful bleeding.
06:03
Differentials: Absolutely each one
behaves a little bit differently.
06:08
Endometriosis,
something called a
regurgitation theory.
06:13
Amazing.
06:14
Watch this.
06:15
So here’s my uterus
and it’s bleeding.
06:17
It’s supposed to move forward, right?
Menses.
06:20
It’s supposed to move forward.
06:22
"Oh, my goodness.
06:23
you’re telling me, Dr. Raj, that’s
it’s going to move backwards?
Yeah, into the fallopian tube.
06:29
Ouch.
06:31
It’s called
regurgitation theory.
06:32
Retrograde menstruation,
back towards the
fallopian tube --
I couldn’t even imagine
what that would feel like –
into the peritoneal cavity.
06:42
Metaplastic theory:
Do you remember when I was talking
to you about how you might have
ectopic implantation of endometrium
on the pelvic peritoneum?
This is the metaplastic theory.
06:53
Endometrium arising from what’s
know as coelomic epithelium.
06:57
If you remember coelom,
that is a primitive,
primitive, primitive structure
back in embryology.
07:02
Amazingly, when you have
such ectopic implantation,
it takes on a
primitive metaplasia.
07:10
Is this crazy?
It really is,
but it’s so connected to so many
different things that you’ve learned.
07:16
Then you have vascular of
lymphatic dissemination theory.
07:19
Clinical features:
Severe dysmenorrhea,
painful sexual intercourse,
dyspareunia,
pelvic pain due to
intrapelvic bleeding,
and periuterine adhesions,
lots of fibrosis.
07:35
Pain upon defecation,
if you’d find endometrium
or ectopic endometrial tissue in the
pouch of Douglas or rectal pouch.
07:43
Dysuria reflects involvement
of the serosa of the bladder.
07:47
Remember, this could
be all over the place.
07:49
Menstrual irregularities are
common presenting complaint.
07:56
If you take a look
at the ovary here,
doesn’t that look like
a chocolate cyst?
Large endometriotic cyst
containing necrotic brown material
consisting of degenerated blood
that looks like a
chocolate cyst.
08:11
I’m sorry,
but we have to describe it exactly
as to what it looks like.
08:16
And technically speaking,
you go ahead and call
this an endometrioma.
08:20
Keep that in mind, okay?
But it’s not a cancer.
08:23
Is that clear?