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Chapter X Endometriosis
CHAPTER X ENDOMETRIOSIS Endometriosis is a neopIasm or tumor growth of aberrant or mispIaced endometria1 tissue which is pecuIiar to the femaIe and has never been found in the maIe. Histologically, it consists of a tissue which resembIes the epitheIium of the endometrium and its underIying stroma. Physiologically, with regard to menstruation, pregnancy and the menopause, it apparentIy is governed by the same Iaws in its reaction to the gIands of interna secretion as is the endometrium Iining the uterine cavity.
What is the etiology of these endometrial prolijerations? There are five theories with regard to their origin. No singIe theory can expIain the various forms of heterotopic endometria1 tissue. I. The Invasion Theory, the “Adenomyoma of Cullen.” CuIIen has shown that there is a direct invasion of the uterine muscuIar waI1 and other tissues by the uterine gIands. HistoIogicaIIy he was abIe to demonstrate a connection between these gIands in the uterine waI1 and the endometrium. 2. Implantation Theory. This theory is most popuIar and was advanced by Sampson. He beIieves that there is a retrograde migration of the endometrium from the uterine cavity through the tubes, with an impIantation of this endometrium on the various structures in the peritonea1 cavity. SeveraI objections have been raised with regard to this theory. It has been held that (I) the endometrium of menstruation is not a viabIe tissue and therefore couId not grow; (2) that it is bathed by menstrua1 bIood which contains trypsin, a proteoIytic enzyme, which shouId prevent its growth, and (3) that the transmura1 Iumen of the tube (i.e. that portion which goes through the uterine waI1) is so smaI1 that it wouId be practicaIIy impossibIe to consider some of the Iarge pieces of endometrium found in the tube as coming from the uterine cavity. Novak beIieves that these pieces of endometrium couId
364
PRACTICAL
CLINICAL
GYNECOLOGY
onIy have been sucked into the Iumen of the tube from the peritonea1 cavity. Opposed to this are the experiments of Jacobson, who CEPHALIC MULLERIAN
DUCT
FIG. 124. Schematic drawing, showing reIationship of Woman and MulIerian ducts. The cephalic portion of the Wolfian duct Iater forms Gartner’s duct. The various parts of the MuIIerian duct go to form A, the FaIIopian tube; B, haIf of the uterus; c, half of the cervix; D, haIf of the upper two-thirds of the vagina.
impIanted endometrium from the uterine cavity of a monkey into the peritonea1 cavity of the same anima1 and had it grow; and of Gay, who cuItured menstrua1 endometrium discharged from the uterine cavity during menstruation, in vitro, and it grew. 3. Direct Transplantation Theory. This expIains the cases where the endometrium is found in scars in the abdomina1 waI1. Two such cases of endometriosis of an abdomina1 scar have been personaIIy observed foIIowing a one-point fixation of the uterus to the abdomina1 waI1. At the point where the b421)
ENDOMETRIOSIS
365
needIe went through the abdominal waII, a mass of endometrial tissue grew. 4. Developmentally Displaced Mullerian or Wolfian Duct Tissue. This was probably the first theory advanced and was presented by von ReckIinghausen. EmbryoIogicaIIy, the MuIIerian duct at its cephaIic extremity deveIops to the outer side of the WoIffIan duct; it then crosses that duct, Iying in front and on top of it and finaIIy ending on the inner side of it. (Fig. 124.) Von ReckIinghausen’s theory was, that, where the MuIIerian and WolffIan ducts cross, some remnants of one or the other ducts (embryona1 rests) remain and Iater deveIop into gIanduIar tissue. 5. Metaplasia of the Peritoneum. Ivanhoff, Meyer, Novak and Lauber have advocated this theory, stating that the endometria1 impIants are the resuIt of a metapIasia of the serosa of the peritoneum, possibIy the end resuIt of an inffammation or of ovarian hormonal stimuIation. A review of the embryoIogy of the ovary and the MuIIerian ducts shows that they are both deveIoped from a modification of the ceIomic epitheIium. (See Fig. 120.) Consequently, the endometrium, the endosaIpinx and the foIIicuIar epitheIium of the ovary are simpIy degrees of differentiation of the ceIomic epitheIium. ShouId some undifferentiated or primitive ceIomic epitheIia1 rests remain anywhere in the peIvis, one might, as Novak states, “get an awakening of the genetic possibiIities in some of the unused ceIomic rests, when stimuIated at the proper time by specific forces.” InA ammation or ovarian secretion couId very we11 be the stimuIating factor. Where are these endometria1 impIants found? CuIIen has shown the various areas where endometriosis is found: (I) adenomyoma of body of uterus; (2) adenomyoma of rectovagina1 septum; (3) adenomyoma of uterine horn or FaIIopian tube; (4) adenomyoma of round Iigament; (5) in hiIum of ovary without a myomatous growth; (6) in uteroovarian ligament; (7) in uterosacra1 Iigament; (8) in sigmoid ffexure; (9) in rectus muscIe and (IO) adenomyoma of the umbiIicus. t2431
3%
PRACTICAL
CLINICAL
GYNECOLOGY
How often does endometriosis occur? In women who have non-infected peIvic organs, the frequency of endometriosis is in direct proportion to the care with which the examination is made. The finding of these impIants does not necessariIy mean that they are giving symptoms. What is the gross pathoIogy of endometriosis and how can it be recognized? They appear earIy as smaI1 bIue noduIes, no Iarger than the head of a pin, on the uterus, ovary, rectovagina1 septum, etc., with dense, puckering adhesions around the smaI1 bIue noduIe. Endometriosis is rareIy singIe; it is aIways muItipIe. These endometria1 areas react to the ovarian hormones in the same manner as the uterine endometrium, so that with each menstrua1 period bIeeding takes pIace in these areas. This bIood is very irritating and causes dense adhesions. The denseness of the adhesions formed by endometriosis is equaIIed onIy by carcinoma. This is evidenced by the fact that unti1 the gross pathoIogy of this Iesion began to be recognized and described by such men as CuIIen, Sampson and others, the Iarge intestine was frequentIy resected for suspected carcinoma. When the Iesion occurs in the rectovagina1 septum, the bIue dome cysts may occasionaIIy be seen in the vault of the vagina with a specuIum. With every period there are fresh exacerbations and impIants. Later these impIants rupture and disseminate over sigmoid, uterosacral Iigaments and the pelvic peritoneum, even anteriorIy over the bIadder. OccasionaIIy the bIood is waIIed off by adhesions, thus forming cysts with fairIy thick waIIs and dense adhesionsexcept at one spot where the cyst waI1 is usuaIIy very thin, so that on attempting to remove the cyst, it ruptures and a thick, dark brown, tarry materia1 is extruded (chocoIate cyst). If the operative specimen is put in formaIin before examination, the endometriosis areas Iose their bIue coIor and cannot be recognized. If one wishes to make a diagnosis from gross pathoIogica1 materia1, fresh tissue must aIways be examined. 12441
ENDOMETRIOSIS
367
What are the symptoms of endometriosis? Endometriosis has never been found before the deveIopment of active sex Iife. The symptoms are not from the endometria1 imprants themseIves, but are attributabIe to the body’s reaction to the irritating bIood extruded by these endometria1 impIants with every menstrua1 period. The most frequent symptom is a graduaIIy increasing dysmenorrhea of such severity that a patient stated; “Doctor, I don’t care what you find, you must remove everything you find that is pathoIogica1; the pain is getting more severe with each period, with the resuIt that now something must be done.” The symptoms are periodic and progressive; they occur at the beginning and just after the menstrua1 period. In the two cases of endometriosis (transpIantation) in an abdomina1 waI1 scar, the patients stated that the tumor mass grew Iarger at each menstrua1 period; foIIowing which it receded, but never to the point where it was before. Increasing constipation, worse at the time of menstruation, is a not infrequent symptom. Other signs and symptoms such as tumor, cystic ovaries and a firm, resistant, noduIar cuI-de-sac are due to associated Iesions, adhesions and coIIections of bIood. A sudden, acute abdomina1 catastrophe may occur as a resuIt of a rupture of one of these coIIections of bIood. How can one make a diagnosis of this condition preoperativeIy
?
Axiom : In order to make a diagnosis of any condition one must first be aware that it occurs. When a patient presents herseIf with a graduaIIy increasing acquired type of dysmenorrhea, occurring mostIy after the menstrua1 period, think immediateIy of endometriosis. Given a patient in whom one can excIude peIvic inff ammatory disease, who presents an increasing acquired dysmenorrhea, indurations in the cuI-de-sac with or without an adherent, fixed retrofIexion, constipation worse at the time of menstruation, the diagnosis of endometriosis must be seriousIy considered, RareIy one may see the bIue domed cysts in the vauIt of the !I2441
368
PRACTICAL
CLINICAL GYNECOLOGY
vagina. This, when associated with the typical symptomatoIogy, is pathognomonic. When the diagnosis is made, or if on opening the peritoneal cavity for some other condition, endometriosis is found, what treatment shaI1 be instituted? The treatment depends upon three factors: (I) The age of the patient; (2) the desire on the part of the woman to retain her capacity for becoming pregnant; and (3) the type of Iesion found. CASE I. A young woman with endometriosis, marked adhesions between the rectovaginal septum and the posterior waI1 of the uterus, severe dysmenorrhea and anxious to become pregnant. The patient is placed in high Trendelenburg position, a left paramedian incision is made and the intestines waIled off. With good light and exposure, the adhesions between the uterus and the rectosigmoid are separated by sharp dissection. If necessary, leave a part of tbe uterus on tbe rectosigmoid rather than a piece of the rectosigmoid on the uterus. The separation of these adhesions releases the uterus, which must be held well out of the pelvis. For this purpose an Olshausen suspension seems to work well. The ovaries, which are usuahy invoIved, are aIso freed and suspended by non-absorbable suture material to the parietal peritoneum above the iliopectineal lines (PooIe suspension). OccasionaIIy, a large raw area may be left in the cul-de-sac. On discharge the patient is advised to become pregnant as soon as she can, as one cannot teI1 when her symptoms may return and castration becomes necessary. PeculiarIy, these patients have great difficulty in There seems to be something which lowers their becoming pregnant. fertility, but just what causes it is not known. CASE XI. A woman in the chiIdbearing period who has endometriosis and has had children, but does not wish to have her ovaries removed. That patient can have the same operative procedure as Case I with the understanding that, should her symptoms return, she will promptIy receive a castration dose of x-ray, which wouId stop the function of her ovaries and prevent further dissemination of the endometriosis. Knowing the diagnosis, one may aIways take a chance and leave the uterus and ovaries in, because on the recurrence of symptoms one can aIways have recourse to a castration dose of x-ray. CASE III. A patient late in her sex Iife, in the late thirties or earIy forties, with an endometriosis. This patient shouId have both ovaries removed and as much endometrial tissue as possible, without damaging any of her other organs. This
U246lt
ENDOMETRIOSIS will stop any further pathology, prevent recurrence of the symptoms, wiII cause those endometria1 impIants present to invoIute.
369
and
What effect has a simpIe hysterectomy, Ieaving both ovaries? Answer: None, as the impIants depend for their continuance of function on the ovaries. Removing the uterus aIone wouId not cure the condition. Question: ShouId a hysterectomy be performed on these patients? Answer: No. Removing the uterus does not cure the condition. To cure the condition, one must stop the ovaries from functioning. The Ioss of the interna secretion of the ovaries stops the growth of the endometria1 impIants. Question : In a young woman, is x-ray castration sufficient? dose wiI1 stop any Answer: I. Yes, an x-ray castration further deveIopment of the pathoIogy, but it wiI1 not cause the pathoIogy that is present to disappear. 2. It is diffIcuIt to castrate a young woman with x-ray. Amenorrhea may be produced for a period of time, but at the end of that time the patient wiI1 again menstruate. ShouId the symptoms recur, a second castration dose can be given. Question: Does x-ray have any effect on the masses themseIves? Answer: No, because the mass is composed of adhesions and bIood. Question: Does endometria1 tissue occur in the tubes? Answer: Yes, Novak has definiteIy shown areas of endometriaI-Iike epitheIium Iining the Iumen of the tube. Question: Is curettage of any vaIue in this condition? Answer: No. Question: Do you often get tarry stooIs in such cases? Answer: No, unIess there is a rupture of a chocoIate cyst into the rectum. Question : Can endometriosis be prevented? Answer: Curtis goes so far as to say that every patient with a third degree retroflexion shouId be operated upon and have a suspension performed to prevent endometriosis. He Question:
b471
370
PRACTICAL
CLINICAL
GYNECOLOGY
beIieves that a third degree retroffexion, according to Sampson’s theory of retrograde spiIIing of the bIood, is the etioIogica1 factor of endometriosis. Question: Do a11 cases of endometriosis require surgica1 or x-ray castration? Answer: No, the majority of cases of endometriosis found are smaI1, asymptomatic and of academic interest onIy. They may Iater cause more severe symptoms. Therefore, when the condition is accidentIy seen at operation, it shouId be recorded in the operative findings. Question: Are a11 bIue domed cysts endometria1 cysts? Answer: No, there are other bIue domed cysts due to cIear Auid. The blue domed endometria1 cyst, when punctured, is found to be fiIIed with bIood or tarry fluid.
What is the etiology of these endometrial prolijerations? There are five theories with regard to their origin. No singIe theory can expIain the various forms of heterotopic endometria1 tissue. I. The Invasion Theory, the “Adenomyoma of Cullen.” CuIIen has shown that there is a direct invasion of the uterine muscuIar waI1 and other tissues by the uterine gIands. HistoIogicaIIy he was abIe to demonstrate a connection between these gIands in the uterine waI1 and the endometrium. 2. Implantation Theory. This theory is most popuIar and was advanced by Sampson. He beIieves that there is a retrograde migration of the endometrium from the uterine cavity through the tubes, with an impIantation of this endometrium on the various structures in the peritonea1 cavity. SeveraI objections have been raised with regard to this theory. It has been held that (I) the endometrium of menstruation is not a viabIe tissue and therefore couId not grow; (2) that it is bathed by menstrua1 bIood which contains trypsin, a proteoIytic enzyme, which shouId prevent its growth, and (3) that the transmura1 Iumen of the tube (i.e. that portion which goes through the uterine waI1) is so smaI1 that it wouId be practicaIIy impossibIe to consider some of the Iarge pieces of endometrium found in the tube as coming from the uterine cavity. Novak beIieves that these pieces of endometrium couId
364
PRACTICAL
CLINICAL
GYNECOLOGY
onIy have been sucked into the Iumen of the tube from the peritonea1 cavity. Opposed to this are the experiments of Jacobson, who CEPHALIC MULLERIAN
DUCT
FIG. 124. Schematic drawing, showing reIationship of Woman and MulIerian ducts. The cephalic portion of the Wolfian duct Iater forms Gartner’s duct. The various parts of the MuIIerian duct go to form A, the FaIIopian tube; B, haIf of the uterus; c, half of the cervix; D, haIf of the upper two-thirds of the vagina.
impIanted endometrium from the uterine cavity of a monkey into the peritonea1 cavity of the same anima1 and had it grow; and of Gay, who cuItured menstrua1 endometrium discharged from the uterine cavity during menstruation, in vitro, and it grew. 3. Direct Transplantation Theory. This expIains the cases where the endometrium is found in scars in the abdomina1 waI1. Two such cases of endometriosis of an abdomina1 scar have been personaIIy observed foIIowing a one-point fixation of the uterus to the abdomina1 waI1. At the point where the b421)
ENDOMETRIOSIS
365
needIe went through the abdominal waII, a mass of endometrial tissue grew. 4. Developmentally Displaced Mullerian or Wolfian Duct Tissue. This was probably the first theory advanced and was presented by von ReckIinghausen. EmbryoIogicaIIy, the MuIIerian duct at its cephaIic extremity deveIops to the outer side of the WoIffIan duct; it then crosses that duct, Iying in front and on top of it and finaIIy ending on the inner side of it. (Fig. 124.) Von ReckIinghausen’s theory was, that, where the MuIIerian and WolffIan ducts cross, some remnants of one or the other ducts (embryona1 rests) remain and Iater deveIop into gIanduIar tissue. 5. Metaplasia of the Peritoneum. Ivanhoff, Meyer, Novak and Lauber have advocated this theory, stating that the endometria1 impIants are the resuIt of a metapIasia of the serosa of the peritoneum, possibIy the end resuIt of an inffammation or of ovarian hormonal stimuIation. A review of the embryoIogy of the ovary and the MuIIerian ducts shows that they are both deveIoped from a modification of the ceIomic epitheIium. (See Fig. 120.) Consequently, the endometrium, the endosaIpinx and the foIIicuIar epitheIium of the ovary are simpIy degrees of differentiation of the ceIomic epitheIium. ShouId some undifferentiated or primitive ceIomic epitheIia1 rests remain anywhere in the peIvis, one might, as Novak states, “get an awakening of the genetic possibiIities in some of the unused ceIomic rests, when stimuIated at the proper time by specific forces.” InA ammation or ovarian secretion couId very we11 be the stimuIating factor. Where are these endometria1 impIants found? CuIIen has shown the various areas where endometriosis is found: (I) adenomyoma of body of uterus; (2) adenomyoma of rectovagina1 septum; (3) adenomyoma of uterine horn or FaIIopian tube; (4) adenomyoma of round Iigament; (5) in hiIum of ovary without a myomatous growth; (6) in uteroovarian ligament; (7) in uterosacra1 Iigament; (8) in sigmoid ffexure; (9) in rectus muscIe and (IO) adenomyoma of the umbiIicus. t2431
3%
PRACTICAL
CLINICAL
GYNECOLOGY
How often does endometriosis occur? In women who have non-infected peIvic organs, the frequency of endometriosis is in direct proportion to the care with which the examination is made. The finding of these impIants does not necessariIy mean that they are giving symptoms. What is the gross pathoIogy of endometriosis and how can it be recognized? They appear earIy as smaI1 bIue noduIes, no Iarger than the head of a pin, on the uterus, ovary, rectovagina1 septum, etc., with dense, puckering adhesions around the smaI1 bIue noduIe. Endometriosis is rareIy singIe; it is aIways muItipIe. These endometria1 areas react to the ovarian hormones in the same manner as the uterine endometrium, so that with each menstrua1 period bIeeding takes pIace in these areas. This bIood is very irritating and causes dense adhesions. The denseness of the adhesions formed by endometriosis is equaIIed onIy by carcinoma. This is evidenced by the fact that unti1 the gross pathoIogy of this Iesion began to be recognized and described by such men as CuIIen, Sampson and others, the Iarge intestine was frequentIy resected for suspected carcinoma. When the Iesion occurs in the rectovagina1 septum, the bIue dome cysts may occasionaIIy be seen in the vault of the vagina with a specuIum. With every period there are fresh exacerbations and impIants. Later these impIants rupture and disseminate over sigmoid, uterosacral Iigaments and the pelvic peritoneum, even anteriorIy over the bIadder. OccasionaIIy the bIood is waIIed off by adhesions, thus forming cysts with fairIy thick waIIs and dense adhesionsexcept at one spot where the cyst waI1 is usuaIIy very thin, so that on attempting to remove the cyst, it ruptures and a thick, dark brown, tarry materia1 is extruded (chocoIate cyst). If the operative specimen is put in formaIin before examination, the endometriosis areas Iose their bIue coIor and cannot be recognized. If one wishes to make a diagnosis from gross pathoIogica1 materia1, fresh tissue must aIways be examined. 12441
ENDOMETRIOSIS
367
What are the symptoms of endometriosis? Endometriosis has never been found before the deveIopment of active sex Iife. The symptoms are not from the endometria1 imprants themseIves, but are attributabIe to the body’s reaction to the irritating bIood extruded by these endometria1 impIants with every menstrua1 period. The most frequent symptom is a graduaIIy increasing dysmenorrhea of such severity that a patient stated; “Doctor, I don’t care what you find, you must remove everything you find that is pathoIogica1; the pain is getting more severe with each period, with the resuIt that now something must be done.” The symptoms are periodic and progressive; they occur at the beginning and just after the menstrua1 period. In the two cases of endometriosis (transpIantation) in an abdomina1 waI1 scar, the patients stated that the tumor mass grew Iarger at each menstrua1 period; foIIowing which it receded, but never to the point where it was before. Increasing constipation, worse at the time of menstruation, is a not infrequent symptom. Other signs and symptoms such as tumor, cystic ovaries and a firm, resistant, noduIar cuI-de-sac are due to associated Iesions, adhesions and coIIections of bIood. A sudden, acute abdomina1 catastrophe may occur as a resuIt of a rupture of one of these coIIections of bIood. How can one make a diagnosis of this condition preoperativeIy
?
Axiom : In order to make a diagnosis of any condition one must first be aware that it occurs. When a patient presents herseIf with a graduaIIy increasing acquired type of dysmenorrhea, occurring mostIy after the menstrua1 period, think immediateIy of endometriosis. Given a patient in whom one can excIude peIvic inff ammatory disease, who presents an increasing acquired dysmenorrhea, indurations in the cuI-de-sac with or without an adherent, fixed retrofIexion, constipation worse at the time of menstruation, the diagnosis of endometriosis must be seriousIy considered, RareIy one may see the bIue domed cysts in the vauIt of the !I2441
368
PRACTICAL
CLINICAL GYNECOLOGY
vagina. This, when associated with the typical symptomatoIogy, is pathognomonic. When the diagnosis is made, or if on opening the peritoneal cavity for some other condition, endometriosis is found, what treatment shaI1 be instituted? The treatment depends upon three factors: (I) The age of the patient; (2) the desire on the part of the woman to retain her capacity for becoming pregnant; and (3) the type of Iesion found. CASE I. A young woman with endometriosis, marked adhesions between the rectovaginal septum and the posterior waI1 of the uterus, severe dysmenorrhea and anxious to become pregnant. The patient is placed in high Trendelenburg position, a left paramedian incision is made and the intestines waIled off. With good light and exposure, the adhesions between the uterus and the rectosigmoid are separated by sharp dissection. If necessary, leave a part of tbe uterus on tbe rectosigmoid rather than a piece of the rectosigmoid on the uterus. The separation of these adhesions releases the uterus, which must be held well out of the pelvis. For this purpose an Olshausen suspension seems to work well. The ovaries, which are usuahy invoIved, are aIso freed and suspended by non-absorbable suture material to the parietal peritoneum above the iliopectineal lines (PooIe suspension). OccasionaIIy, a large raw area may be left in the cul-de-sac. On discharge the patient is advised to become pregnant as soon as she can, as one cannot teI1 when her symptoms may return and castration becomes necessary. PeculiarIy, these patients have great difficulty in There seems to be something which lowers their becoming pregnant. fertility, but just what causes it is not known. CASE XI. A woman in the chiIdbearing period who has endometriosis and has had children, but does not wish to have her ovaries removed. That patient can have the same operative procedure as Case I with the understanding that, should her symptoms return, she will promptIy receive a castration dose of x-ray, which wouId stop the function of her ovaries and prevent further dissemination of the endometriosis. Knowing the diagnosis, one may aIways take a chance and leave the uterus and ovaries in, because on the recurrence of symptoms one can aIways have recourse to a castration dose of x-ray. CASE III. A patient late in her sex Iife, in the late thirties or earIy forties, with an endometriosis. This patient shouId have both ovaries removed and as much endometrial tissue as possible, without damaging any of her other organs. This
U246lt
ENDOMETRIOSIS will stop any further pathology, prevent recurrence of the symptoms, wiII cause those endometria1 impIants present to invoIute.
369
and
What effect has a simpIe hysterectomy, Ieaving both ovaries? Answer: None, as the impIants depend for their continuance of function on the ovaries. Removing the uterus aIone wouId not cure the condition. Question: ShouId a hysterectomy be performed on these patients? Answer: No. Removing the uterus does not cure the condition. To cure the condition, one must stop the ovaries from functioning. The Ioss of the interna secretion of the ovaries stops the growth of the endometria1 impIants. Question : In a young woman, is x-ray castration sufficient? dose wiI1 stop any Answer: I. Yes, an x-ray castration further deveIopment of the pathoIogy, but it wiI1 not cause the pathoIogy that is present to disappear. 2. It is diffIcuIt to castrate a young woman with x-ray. Amenorrhea may be produced for a period of time, but at the end of that time the patient wiI1 again menstruate. ShouId the symptoms recur, a second castration dose can be given. Question: Does x-ray have any effect on the masses themseIves? Answer: No, because the mass is composed of adhesions and bIood. Question: Does endometria1 tissue occur in the tubes? Answer: Yes, Novak has definiteIy shown areas of endometriaI-Iike epitheIium Iining the Iumen of the tube. Question: Is curettage of any vaIue in this condition? Answer: No. Question: Do you often get tarry stooIs in such cases? Answer: No, unIess there is a rupture of a chocoIate cyst into the rectum. Question : Can endometriosis be prevented? Answer: Curtis goes so far as to say that every patient with a third degree retroflexion shouId be operated upon and have a suspension performed to prevent endometriosis. He Question:
b471
370
PRACTICAL
CLINICAL
GYNECOLOGY
beIieves that a third degree retroffexion, according to Sampson’s theory of retrograde spiIIing of the bIood, is the etioIogica1 factor of endometriosis. Question: Do a11 cases of endometriosis require surgica1 or x-ray castration? Answer: No, the majority of cases of endometriosis found are smaI1, asymptomatic and of academic interest onIy. They may Iater cause more severe symptoms. Therefore, when the condition is accidentIy seen at operation, it shouId be recorded in the operative findings. Question: Are a11 bIue domed cysts endometria1 cysts? Answer: No, there are other bIue domed cysts due to cIear Auid. The blue domed endometria1 cyst, when punctured, is found to be fiIIed with bIood or tarry fluid.