Endometrioma

ENDOMETRIOMA, a tumor-like formation built on the type of endometrium. It occurs in sexually mature women aged 30-50 years in the pelvic organs, and also extraperitoneally. Morphologically, an E. represents a branching, indistinctly delimited from neighboring tissues glandular proliferation, possessing an infiltrating growth and having a cystic, spongy appearance. Microscopically, the glands are lined with flat, cuboidal, and ciliated columnar epithelium. The stroma is rich in cells and bundles of smooth muscle fibers adjoin it; in other words, there is a picture fully similar in its structure to the mucous membrane of the uterus. The similarity increases even more, since this formation periodically 'menstruates,' i.e., in connection with menstruations it swells, increases, and begins to bleed. In the stroma during this, a premenstrual decidual metamorphosis is noted. In the lumens of the glands, protein masses and often hemosiderin are found. In terms of its localization, an E. can occur within the uterus, in its inner and outer layers; however, due to the pathogenetic peculiarities of these cases, the E. of the uterus is better considered separately and such cases are designated as adenomyosis of the uterus. Typical localizations of endometrioma are the tubes, ovaries, ligaments of the uterus, especially the round and broad ligaments, the wall of the sigmoid and rectum, the appendix. Moreover, an E. occurs in the navel area in postoperative scars of the anterior abdominal wall, especially in connection with operations on the uterus, in the groin area, in the wall of the bladder, in the vagina, paravaginal connective tissue, and the vulva. The view of an E. as a tumor is now abandoned by everyone, and many prefer to designate it as adenomyosis or endometrioid growths (endometriosis). From the concept of endometrioma one should distinguish the concept of adipomyoma (see). Regarding the pathogenesis of an E., several theories exist. The least probable is the assumption of the congenital nature of these growths. Some support in the literature is found by the American theory of Sampson. The latter considers that the primary source of endometrioid growths is the epithelium of the uterus, which during retrograde menstruations can allegedly be transported through the tubes into the abdominal cavity, where it implants. Without touching upon the question of retrograde menstruations, which are not recognized by everyone, this theory in any case cannot explain all cases of an E., for example, localization in the navel area, in the groin outside connection with the abdominal cavity and without any preceding operations. It is difficult to imagine, according to this theory, the localization of an E. in a postoperative scar of the anterior abdominal wall 10-15 years after the operation (the case of Pankow). A wide support among researchers (R. Meyer, Franque, Josselin de Jong, etc.) is enjoyed by the theory according to which an E. can arise from peritoneal epithelium, which as a coelomic epithelium, having embryological kinship with ovarian epithelium and Müllerian ducts, can give rise through metaplasia to a complex organoid formation. Here the question is not about simple metaplasia of peritoneal epithelium into columnar or its ability to give a decidual reaction (such a possibility is well known in pathology), but about the construction from peritoneal epithelium of a formation containing all elements of endometrium and its identity not only morphologically but also in terms of function. The possibility of such complex bioplastic metaplasia must now be resolved in the affirmative sense. This point of view makes it possible to subsume a single genesis for all cases of an E. According to this theory, the localization of an E. in the navel area and equally in the groin is explained by the presence in these places of persistent remnants of physiological fragments of the peritoneum (remnants of processus vaginalis peritonaei). The same can be said about the localization of endometrioid growths in surgical scars, where parts of the peritoneum can easily be trapped in the suture. As for the cause of the occurrence of an E. in this or that place, the majority of authors consider this phenomenon to be of a compensatory order and occurs in connection with disturbances of the function of the female genital organs, in particular the uterus (hypofunction of the uterus). The clinical picture of an E. is determined, on the one hand, by the depth of infiltration of the E. into the tissues, on the other hand, by its localization. Possessing an infiltrating growth, an E. in rare cases can behave like a malignant tumor. Thus, cases of retroperitoneal E., which, penetrating the pelvic organs (vagina, rectum, urethra, bladder), caused severe disorders in the form of stenosis and ulcerations, are known in the literature. Penetration of the bladder can give hematuria with each menstruation. It is important to note that during menstruations, unbearable pains in the abdomen (irritation of the peritoneum) and bleeding into the abdominal cavity can appear in cases of intra-peritoneal localization of an E. One should always remember the possibility of such a complex of phenomena in cases of unclear diagnosis of ectopic pregnancy. An E. of the tube can be one of the causes of tubal pregnancy, all the more so since a decidual metamorphosis of the tube can be observed in this case, which facilitates the implantation of the egg here. Cases of interstitial pregnancy are known with localization of an E. in the uterine part of the tube. On the other hand, an E. of the tube can lead to the infertility of the woman in connection with the blockage of the lumen of the tube with mucus. In microscopic diagnosis, an E. of the tube should be distinguished from local proliferations of inflammatory nature of the mucous membrane, the so-called salpingitis isthmica, nodosa, which have nothing in common with an E. but can be morphologically similar to it. An E. of the navel area and in postoperative scars swell, increase, and begin to bleed in connection with menstruations, causing much discomfort to their bearers. With the onset of the climacteric period, an E. undergo involution and senile atrophy and no longer bother (the case of Ushakov). The transition of an E. to cancer represents a huge rarity (single cases in world literature). Of therapeutic measures, besides operative removal, one can act on an E. by X-rays through the ovaries; however, in 10% of cases they continue to develop further. Lit.: Talalaev V., On endometrioid growths in women, Mosk. med. zhurn., 1927, No. 7; Shvartsman E., Modern state of the question on endometriosis, Gig. i akush., 1934, No. 3; Nagelitz H., Clinical, pathogenetic and experimental investigation of endometriosis, Oslo, 1934 (lit.); Kleine H., Genese und Klinik der Endometriosis, Klinische Wochenschrift, 1934, No. 1.