12PV NIUB : Normal Vagina : Normal mucosa, no bloody discharge Cervix : no abnormal discharge per os, no cervicalmotion tenderness, no endocervical polypUterus : Normal size not tenderAdnexa : right adnexal mass size 3cmCul-de-sac : no bulging, no free fluid
13Problem list Progressive dysmenorrhea 3 months PTA Metrorrhagia 10 years PTANocturia 1 years PTADeep dyspareunia 10 years PTAAbnormal PV examination ; right adnexal mass
15Investigation Ultrasound Pap smear Complete blood count BUN , Creatinine , ElectrolyteUrinalysis
16Transvaginal USG Uterus ; Body length 5.21 mm AP diameter 4.06 mm Subserous myoma 3.32 x 3.53 x 2.5 cmIntramural myoma at anterior wall 1.84 x 1.69 x 1.67 cmLeft Ovary ; ground glass appearance cyst 4.1 x 3.18 x 2.92 cmRight Ovary Diameter 3.59 x 2.5 cm ; ground glass appearance cyst 2x 1.58 cm ,
17Pap smear Negative for intraepithelial lesion or malignancy Fungal organisms morphologically consistent with Candida spp.
22Medical therapiesAromatase inhibitor – inhibit local estrogen production in endometriotic implants themselves as well as in ovary, brain, and adipose tissueOral Contraceptives - Relieve dysmenorrhea through ovarian suppression and continuous progestin administrationProgestins - Inhibit growth of lesions by inducing decidualization followed by atrophy of uterine-type tissue
23Nonsteroidal Anti-inflammatory Drugs - Proven efficacy for treatment of primary dysmenorrhea Danazol® - Inhibits midcycle FSH and LH surges and prevents steroidogenesis in corpus luteumGonadotropin-Releasing Hormone Agonists - Produces hypogonadotrophic-hypogonadic state through downregulation of pituitary gland , GnRH agonists as effective as other medical therapies in relieving pain and reducing progression
25Indications for surgical management of endometriosis include: diagnosis of unresolved pelvic painsevere, incapacitating pain with significant functional impairment and reduced quality of lifeadvanced disease with anatomic impairment (distortion of pelvic organs, endometriomas, bowel or bladder dysfunction)failure of expectant/medical managementendometriosis-related emergencies, ie, rupture or torsion of endometrioma, bowel obstruction, or obstructive uropathy
28Post – operative noteDiagnosis: Myoma uteri with bilateral endometriotic cystProcedure: TAH with Right SO and left cystectomyPositive Finding:- Uterus: Globular shape- Adnexsa: Severe adhesion at Left sideEndometrioma cyst at both left and right ovaries- cul de sac: adhesionOperation Procedure- Midline incision was done- Adbominal wall was opened layer by layer- Identify uterus, adnexa, ovaries and tubes- Round ligaments were cut, clamped and ligated- total abdominal hysterectomy- right salpinge and ovary were resected.- left ovarian endometrioma was resected.