{"paper_id":"9ca79bb3-d1f8-402f-bd74-91f2409c4e24","body_text":"Undang Gani Suriatmaja, Giofani Magdalena, Welly \nRatwita \nMedical Faculty \nUniversitas Jenderal Achmad Yani  \nCimahi, Indonesia \nTrisnu Kamajaya* \nMedical Faculty \nUniversitas Udayana Kampus Bukit \nBadung, Indonesia \n*trisnukamajaya@aol.com\nAbstract—Endometriosis is one of common gynecologic \ndisease that mostly founded in reproductive age. The Presence of \nabnormal endometrial tissues, decreasing quality of life to \npatients due to pain like dysmenorrhea. The diagnosed can be \nfound based on clinical app earance by laparoscopic method as \nthe gold standard of diagnosing this case. This study was \nconducted to describe the patient’s endometriosis with clinical \nsymptom and results of laparoscopic in RSUP Dr. Hasan Sadikin \nBandung from 2016 to 2018. This descri ptive study recruit 100 \nsamples. Data of age collected from secondary data. The data was \ngrouped then processed and presented in tubular form. Most of \nthem here are within reproductive age in 30 -34 yars of age at \n28%, are mostly nulliparous 73%, with most clinical symptoms \nof dysmenorrhoea in 74%, and the most common location were \nto be found within ovarium as much as 85%. According to the \nstudy, we can describe that reproductive age and nulliparous \nwere the most dominant characteristic, and most of the cli nical \nsymptom are referring to dysmenorrhoea and most anatomical \nlocation are within ovarium. \nKeywords—\n endometriosis, laparoscopic, diagnostic \nI. INTRODUCTION\nEndometriosis is the growth of endometrial tissue, glands, \nand stroma outside the uterine cavity or in the myometrium. \nWhen endometrial tissue is present in the myometrium, it is \ncalled adenomyosis. Endometriosis occurs very frequently in \nthe ovaries, broad ligament, and peritoneal surfaces of the \nDouglas cavity, including the uterosacral ligament, posterior \ncervix, etc., rectovaginal septum [1-3]. Endometriosis occurs in \n1 to 10 women of reproductive age. The Endometriosis \nAssociation Research Registry conducted a study of 3020 cases \nof endometriosis and found 2-4% at reproductive age, 40.6% at \n<20 years, 42.9% at 20-29, and 16.5% at 30-39 year [4-6]. The \nproblems that are often complained about in endometriosis \npatients are chronic pelvic pain and infertility [7]. Based on \nWiweko et al. 2013 the most seen manifestation were \ndysmenorrhea (81%), infertility disorders (33.7%), low back \npain (32.5%), dyspareunia (20.9%), constipation (13.9%), \ndysuria (6.9%), and dyschezia (4.6%) [8]. According to the \n1997 revision of the American Society for Reproductive \nMedicine, the staging classification of endometriosis is based \non the type, location, appearance, depth of lesion invasion, \ndisease spread, and adhesions. The gold standard examination \nperformed to diagnose endometriosis is diagnostic laparoscopy \n[9]. Based on the description above, researchers are interested \nin conducting research that is will be done in Dr. Hasan \nSadikin Bandung, which is the highest referral hospital in West \nJava. This research will look for a picture of clinical symptoms \nand the anatomical location of endometriosis based on the \nresults of the diagnostic laparoscopy at Obstetrics and \ngynecology polyclinic Dr. Hasan Sadikin Bandung for the \nperiod 2016-2018. \nA. Ethiopathogenesis\nThe retrograde menstruation theory was developed by\nSampson in 1927. This was confirmed by a laparoscopic \nexamination which proved that there was a reverse flow of \nmenstrual blood that flowed back through the tube into the \npelvic cavity (retrograde). Based on this theory, endometriosis \nis a consequence of the backflow of menstrual blood through \nthe fallopian tubes, which continues with implantation and \ngrowth in the peritoneum and ovaries [7].  \nLymphatic and vascular embolism theory explains the \nmechanism of endometriosis in the outer regions pelvis. The \nretroperitoneal area has a lot of lymphatic circulation. A study \nshowed that 29% of women suffering from endometriosis was \nfound lymph nodules in the pelvis. In addition, the spread of \nadenocarcinoma via the lymphatic route supports the theory \nthat endometriosis can spread via the lymphatic route [7]. \nCoelomic Metaplasia Theory was put forward by Robert \nMeyer, who stated that endometriosis occurs due to certain \nAdvances in Health Sciences Research, volume 37\nProceedings of the 12th Annual Scientific Meeting, Medical Faculty, Universitas Jenderal Achmad Yani,\nInternational Symposium on \"Emergency Preparedness and Disaster Response during COVID 19 Pandemic\" (ASMC 2021)\nClinical Manifestation and Anatomical Location of \nEndometriosis Based on the Diagnostic Laparoscopic\nResult \n(From Obstetric and Gynecology Policlinic RSUP Dr. Hasan Sadikin Bandung within \n2016-2018) \nCopyright © 2021 The Authors. Published by Atlantis Press International B.V.\nThis is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 222\n\nstimulation, were to be dominantly coming from hormone \nwithin parietal peritoneum cell which is a pluripotent tissue [7]. \nImmunologic and genetic theory were to seen as immune \ndisorders occur in women who suffer from endometriosis. A \nstudy found a failure in the system for collecting and removing \nwaste substances during menstruation by macrophages and \ndecreased Natural Killer (NK) cell function in endometriosis. \nSeveral studies have found an increase in Immunoglobulin A \n(IgA), IgG and IgM in the pe ritoneal serum of patients with \nendometriosis [7]. \nB. Anatomical Location and Manifestation of Endometriosis \nMost commonly, endometriosis is found in the pelvic area. \nThe ovaries, pelvic peritoneum, anterior and posterior cul -\ndesac, and uterosacral ligaments are also frequently involved. \nIn addition, it can be fo und in the rectovaginal septum, ureters \nand bladder. The clinical symptoms of endometriosis will peak \nin the premenstrual state, then sub side after menstruation is \nover [7]. Pelvic pain is the most common symptom. Other \nsymptoms are dysmenorrhea, pain in t he bladder or dysuri a, \ndyspareunia, dyschezia, and s ome patients even present  with \ncomplaints of infertility [10,11]. \nC. Risk Factors  \nGenetics as a risk factor was studied in the Oxford \nEndometriosis Gene (OXEGENE) study, an international \ncollaborative project that has attempted to identify the locus of \nvulnerability using linkage analysis. Which  is significant on \nchromosome 10q26. Chromosome 10q26 has previously been \ninvolved in gene studies, and the results reported aberrant \nendometrial EMX2 expression in women with endomet riosis. \nEMX2 itself plays a role in coding the transcription factors \nneeded in the development of the reproductive tract. But to \ndate, there are no official studies that confirm whether EMX2 \ncontributes or not to the development of endometriosis [12,13]. \nMeanwhile, women whose mothers or sisters have \nendometriosis have a seven times greater risk of experiencing \nendometriosis. The incidence of endometriosis is 10 -20% in \nwomen of reproductive age, rarely occurs at th e age of \npremenars or menopause [14]. Women w ith short menstrual \ncycles can increase the risk of exposure to menstruation which \nwill have an increased risk of retrograde menstruation/reflux, \nmaking it easier for endometriosis. This shortening of the \nmenstrual cycle increases the hormone estrogen expo sure \ncompared to women who have long menstrual cycles [15].  \nThe development and growth of endometriosis tissue \ndepend on sex steroid hormones and local growth factors such \nas insulin-like growth factor 1 (IGF -1) or vascular endothelial \ngrowth factor (VEGF). Estrogen increases sharply in the short \ntime before ovulation; estrogen itself has a synergistic effect \nwith IGF-1 / VEGF and sometimes actually enhances the effect \nof IGF -1 / VEGF on the proliferation and mitosis of ectopic \nendometrial cells, which will  result in the formation of \nendometriosis [16]. During the menstrual cycle of patients with \nendometriosis, cyclic bleeding can occur in the nasal cavity, \nwhich occurs due to the presence of estrogen receptors on the \nmucosal surface of the respiratory tract;  this can occur due to \nan imbalance in the secretion of matrix metalloproteases \n(MMPs) and tissue inhibitor of metalloproteases (TIMPs) [17]. \nD. Diagnosing Endometriosis \nThe physical examination of endometriosis begins with an \ninspection of the using  a speculum, followed by bimanual \nexamination and palpation of the rectovagina. Examination \nduring menstruation can increase the chances of detecting \nendometriosis nodules and also assess pain [7,18]. \nUltrasound is used as the first -line examination performed \non patients where the pelvic di sease is suspected. Ultrasound \nhas good resolution, easy accessibility, is inexpensive, and free \nfrom radiation. Although ultrasound has limitations for \ndiagnosing peritoneal endometriosis, it is very effective in \ndiagnosing endometrioma. \nMRI is a good alt ernative non-invasive diagnostic method \nwhere the entire pelvic state can be visualized with high \nspecificity and sensitivity, especially for detecting deep \ninfiltrating endometriosis / deep nodular endometriosis and \nendometrioma. The disadvantage of MRI i s its inability to \ndetect small (<3mm) peritoneal lesions [10]. \nLaparoscopy is the main method or gold standard used to \ndiagnose endometriosis. Laparoscopic findings that were seen \nwere discrete endometriosis lesions, endometrioma, and \nadhesions formation. The examination is carried out during the \nmenstrual cycle in the proliferative phase until the early \nsecretory phase so that endometriosis can be visualized \nproperly. Operative laparoscopy requires three basic \ncomponents, namely skills, equipment, instrume nts, operating \nroom facilities, and an operating team trained. Its advantages \nare minimal bleeding, a high degree of operative precision, low \ncomplications, short treatment time, and minimal surgical \nwounds [7,8,19]. \nII. RESEARCH METHODS \nThis research method is descriptive research. This study \nused secondary data, namely the medical records of \nendometriosis patients with clinical symptoms and the results \nof laparoscopy at the Obstetrics and Gynecology Polyclinic of \nDr. Hasan Sadikin Bandung for the period 2016 -2018. From \n417 medical records of p atients with a diagnosis of \nEndometriosis, the study sample was selected. It was obtained \n220 medical records of patients diagnosed with Endometriosis, \nwhich performed diagnostic laparoscopy in accordance with \nthe inclusion and exclusion criteria, then the  number of \nsamples in this study was 100 samples using the simple random \nsampling method. The variables in this study were age, parity, \nclinical features, and anatomical location. \n \nAdvances in Health Sciences Research, volume 37\n223\n\nIII. RESULTS AND DISCUSSION \nA. Description of Age Characteristics of Endometriosis \nPatients in Obstetrics and Gynecology Polyclinic Dr. \nHasan Sadikin Bandung within 2016-2018 \nTABLE I.  DESCRIPTION OF THE CHARACTERISTICS OF ENDOMETRIOSIS \nPATIENTS BY AGE \nAge (year) n % \n20-24 23 23 \n25-29 20 20 \n30-34 28 28 \n35-39 17 17 \n40-44 12 12 \n45-49 0 0 \nTotal 100 100 \n \nBased on Table 1 the description of age within 100 \nendometriosis patient group found that the age of \nendometriosis patients at the Obstetrics and Gynecology \nPolyclinic Dr. Hasan Sadikin Bandung for the period 2016 -\n2018 were mostly in the age range 30 -34 years with a total of \n28 people (28%) [20]. This study's results are almost the same \nas research conducted by  Hestiantoro et al. shows that the \nlargest age group is 30 -34 years (29.72%). The results of this \nstudy indicate that endometriosis in women of reproductive age \nwill have a greater effect on the quality of life of these patients. \nTherefore, early case find ings will reduce serious \ncomplications so as not to affec t the patient's quality of life \n[21]. \nB. Description of Parity Characteristics of Endometriosis \nPatients in Obstetrics and Gynecology Polyclinic Dr. \nHasan Sadikin Bandung Period 2016-2018 \nTABLE II.  CHARACTERISTICS OF PARITY WITHIN ENDOMETRIOSIS \nParity n % \nNullipara (P0) 73 73 \nPrimipara (P1) 19 19 \nMultipara (P2) 3 8 \nTotal 100 100 \n \nFrom what we could see from Table 2, shows that the most \nendometriosis patients were to be dominantly nulliparous, with \na total of 73 people (73%). The results of this study are in \naccordance with research conducted by A badi, which was \nfound to be almost the same, showing that 46% of patients \nwere nulliparous. Research conducted by Rajuddin and Jacoeb \nis also in line with the results of this study which found 26 \ncases (81.3%) were to be nulliparous. Based on several clinical \nand epidemiological research data results, there is an indication \nof a relationship between a history of parity and a risk factor \nfor endometriosis [21]. \nC. Overview of Clinical Symptoms of Endometriosis Patients \nin Obstetrics and Gynecology Polyclinic Dr. Hasan \nSadikin Bandung Period 2016-2018 \nTABLE III.  DESCRIPTION OF CLINICAL SYMPTOMS OF PREDOMINANT \nCOMPLAINTS WITHIN ENDOMETRIOSIS PATIENTS \nChief Complaint n % \nDysmenorrhea 74 74 \nInfertility 20 20 \nPelvic Pain 5 5 \nDyspareunia 1 1 \nDisuria 0 0 \nDyskezia 0 0 \nTotal 100 100 \n \nTable 3, show that the most common complaint is \ndysmenorrhea, with a total of 74 people (74%). The results of \nthis study are in accordance with research conducted by Abadi, \nwhich showed that dysmenorrhea was the most frequently \ncomplained of symptoms, namely 23 cases (70%). Another \nstudy conducted by Pangemanan et al . showed that \ndysmenorrhea was found in 31 cases (93.9%) [18].  \nThe clinical symptoms felt by the patients were mostly \ndysmenorrhea; this is related to the role of proinflammatory \ncytokines that act on endometriosis lesions resulting in the \nproduction of large amounts of prostaglandin E2 (PGE2), and it \nmay increase neuronal invasion by stimulating the formation of \nNGF and other neurotrophins. This results in persistent \ninflammatory pain and inhibits neuronal apoptosis. There was \nan increase in nerve fib er density in peritoneal lesions of \nwomen with endometriosis compared  to women without \nendometriosis [22]. The data from the dysmenorrhea group \nwere more frequent in lesions in the uterus, whereas from this \nstudy, it was found that the location of the lesi ons was mostly \nin the ovaries. \nInfertility was also found in this study, as much as 20%. \nBecause the abnormal cell growth of endometriosis will grow \nalong with the increase in body estrogen and progesterone \nlevels. Endometrial tissue grows outside the uter us from the \nfallopian tubes infundibulum to the ovary were the most \ndominant location where it develops. Therefore, the ovary is \nthe first part of the pelvic cavity to be affected by \nendometriosis [23]. Adhesions can also occur around the uterus \nand fallopian tubes. Adhesions in the uterus cause the uterus to \ngrow retrovert, while adhesions in the fallopian tubes cause the \nspontaneous movement of the fimbriae's ends to carry the \novum to the uterus to be obstructed. These things cause \ninfertility in endomet riosis. Chronic pelvic pain in \nendometriosis can also be caused by irritation and infiltration \nof the pelvic floor nerves. Chronic pelvic pain occurs when the \nendometriosis lesion is on the lateral wall of the pelvis. \nDysuria is a symptom of endometriosis that is rarely \ncomplained of by endometriosis patients. This is based on the \ntheory that dysuria is caused by infection. So that the diagnosis \nof endometriosis may be suspected if the urine culture results \nare negative. Dychezia is also a minor common symp tom in \nAdvances in Health Sciences Research, volume 37\n224\n\npatients with endometriosis. Dyschezia usually reflects the \npresence of a rectosigmoid endometriosis implant. \nD. Overview of the Anatomical Location of Endometriosis \nPatients in the Obstetrics and Gynecology Polyclinic Dr. \nHasan Sadikin Bandung Period 2016-2018 \nTABLE IV.  OVERVIEW OF LAPAROSCOPIC RESULTS FOR ENDOMETRIOSIS \nPATIENTS BASED ON THE LOCATION OF THE ENDOMETRIOSIS \nEndometriosis location n % \nOvarium 85 85 \nUterus 7 7 \nFallopian Tube 8 8 \nExternal Organ 0 0 \nTotal 100 100 \n \nTable 4  shows that the anatomica l location of the most \nendometriosis patients is the ovary, with a total of 85 people \n(85%). The results of this study are in accordance with that \nconducted by Abadi. It was found that the largest distribution \nwas the ovaries, as many as 27 cases (82%). Th en another \nstudy conducted by Pangemanan et al. (2007) also obtained the \nsame results, namely from 33 endometriosis patients, 26 \npatients (78.8%) of whom were located in the ovary [18]. \nEndometriosis can occur because menstrual blood flows \nback through the  tubes into the pelvic cavity (retrograde). So \nthat the ovary can become the pelvic organ most often affected \nby the en dometriosis process [3]. Endometrial cells in the \novary can enter the bloodstream and spleen because they are \ninfluenced by hormonal cycl es, so when changes in estrogen \nand progesterone levels are lower or reduced, this endometrial \ntissue there will be necrosis and bleeding in the pelvic area. \nBleeding in the pelvic area is caused by irritation of the \nperitoneum and ca uses dysmenorrhoea [10,13]. Endometriosis \nthat occurs in the ovaries can form brown cysts or often refer to \nas brown cysts, which can cause adhesions with other organs \nand form a complete unity. The features of ovarian \nendometriosis vary, from small lesions to large cysts [10]. \nIV. CONCLUSION \nBased on research at the Obstetrics and Gynecology \nPolyclinic Dr. Hasan Sadikin Bandung for the 2016 -2018 \nperiod can draw conclusions (1) The characteristics of \nendometriosis patients based on age were mostly in the age \nrange 30-34 years as man y as 28 people (28%), and based on \nthe most parity nulliparous were to be dominantly found as \nmany as 73 people (73%) (2) The most common complaint was \ndysmenorrhea within 74 people (74%). (3) The anatomical \nlocation of endometriosis is mostly found in the ovaries, with a \ntotal of 85 people (85%). \nFor further research, it is also advisable to look at the types \nof endometriosis lesions, as well as the relationship between \nendometriosis and the incidence of infertility in these patients. \nFor further research,  advisable to do research with wider \nvariables and with different data processing as it will increase \nthe knowledge of other students about endometriosis. \n \nREFERENCES \n \n[1] B.L. Hoffman, J.O. Schorage, K.D. Bradshaw, L.M. Halvorson, J.I. \nSchaffer, and M.M. Corton, Williams Gynecology, 3rd ed. New York: \nMcGraw Hill, 2016, pp. 285-7. \n[2] N.F. Hacker, J.C. Gambone, and C.J. Hobel, Hacker & Moore's \nessentials of obstetrics and gynecology. Germany: Elsevier Health \nSciences, 2015. \n[3] J.S. Berek, Berek & Novak’s Gynecology, 14th Edition.  Philadelphia: \nLippincott Williams & Wilkins, 2007, pp. 1138-56.  \n[4] P.A. Rogers, T.M. D’Hooghe, A. Fazleabas, C.E. Gargett, L.C. Giudice, \nG.W. Montgomery, ... and K.T. Zondervan, “Priorities for endometriosis \nresearch: recommendations from an i nternational consensus workshop,” \nReprod sci., vol. 16, no. (4), pp. 335-46, 2009. \n[5] S. Abbas, P. Ihle, I. Köster, and I. Schubert, “Prevalence and incidence \nof diagnosed endometriosis and risk of endometriosis in patients with \nendometriosis-related symptoms: findings f rom a statutory health \ninsurance-based cohort in Germany, ” European Journal of Obstetrics & \nGynecology and Reproductive Biology, vol. 160, no. (1), pp. 79-83, \n2012. \n[6] W. Hanifa, Gynecology, Third Edition. Jakarta: PT. Bina Pustaka \nSarwono Prawiharjo, 2011, pp. 239-40. \n[7] J.O. Schorge, J.I. Schaffer, L.M. Halvorson, B.L. Hoffman, K.D. \nBradshaw, and F.G. Cunningham, Williams gynecology, 2nd ed. China: \nThe McGraw-Hill, 2012, pp. 281-98. \n[8] B. Wiweko, C.G. Puspita, K. Sumapraja, M. Natadisastra, A.K. Harzief, \nH. Situmorang, ... and A. Hestiantoro, “Penggunaan DLBS1442 untuk \nTerapi Medikamentosa Terki ni pada Penderita Endometriosis, ” Med \n2017, vol. 26, no. (2), pp. 4-7, 02 August 2017. \n[9] L. Speroff and M.A. Fritz, “Endometriosis,” In: Clinical Gynecologic \nEndocrinology and Infertility , 8th ed. Philadelphia: Lip pincott William \n& Wilkins, 2018, p. 955. \n[10] S.J. Bagaria, D.D. Rasalkar, and B.K. Paunipagar, Endometriosis – basic \nconcepts aand current research trends. China: InTech, 2012, pp. 437-46. \n[11] B.A. Magowan, P. Owen, and J. Drife, Clinical obstetrics & \ngynaecology, 2nd ed. China: Saunders Elsevier, 2009, pp. 1-140. \n[12] S. Kennedy, “The genetics of endometriosis, ” European Journal of \nObstetrics & Gynecology and Reproductive Biology, vol. 82, no. (2), pp. \n129-133, 1999. \n[13] S. Prawihardjo, “Endometriosis,” Dalam M. Anwar, A. Baziad, dan R.P. \nPrabowo, Ilmu Kandungan,  Edisi 3. Jakarta: PT B ina Pustaka Sarwono \nPrawihardjo, 2011, pp. 239-49. \n[14] K.C. Abadi, Gambaran endometriosis di laboratorium patologi anatomi \nRSUP DR. M . Djamil Padang periode 2010 -2013. Padang: Fakultas  \nkedokteran Universitas Andalas, 2014. \n[15] M. Wei, Y. Cheng, H. Bu, Y. Zhao, and W. Zhao, “Length of menstrual \ncycle and risk of endometriosis: a meta -analysis of 11 case –control \nstudies,” Medicine, vol. 95, no. (9), p. 2922, 2016. \n[16] N. Machairiotis, A. Stylianaki, G. Dryllis, P. Zarogoulidis, P. \nKouroutou, N. Tsiamis, ... and C. Machairiotis, “Extrapelvic \nendometriosis: a rare entity o r an under diagnosed condition? ” \nDiagnostic Pathology, vol. 8, no. (1), pp. 1-12, 2013. \n[17] E. Weisberg and  I.S. Fraser, “Contraception and endometriosis: \nchallenges, efficacy, and therapeutic importance, ” Open access j ournal \nof contraception, vol. 6, pp. 105-15, 2015. \n[18] A.L. Mounsey, A.S. Wilgus, and C. David, “Diagnosis and management \nof endometriosis,” J Am Fam Physician , vol. 74, no. (1),  pp. 594-602, \n2006. \nAdvances in Health Sciences Research, volume 37\n225\n\n[19] W. Hadisaputra, “Perkembangan La paroskopi Operatif di Indonesia, ” \neJKI, vol. 2, no. (2), pp. 65-9, 2014. \n[20] A. Hestiantoro, A. Baziad, dan A. Puspasari, Karakteristik Pasien \nEndometriosis di Rumah Sakit Dr. Cipto Mangunkusumo Periode 2000 -\n2005. Jakarta: Fakultas Kedokteran Universitas Indonesia, 2007. \n[21] Rajuddin dan T.Z. Jacoeb, “Penanganan Adenomiosis dengan Reseksi \nLaparotomi,” Dalam Majalah Obstetri Ginekologi Indonesia, vol. 32, no. \n(1) (Edisi Januari), pp. 23-25, 2008. \n[22] P. Vercellini, L. Fedele, G. Aimi, G. Pietropaolo, D. Consonni, and P.G. \nCrosignani, “Association between endometriosis stage, lesion type, \npatient characteristics and severity of pelvic pain symptoms: a \nmultivariate analysis of over 1000 patients, ” Human reproduction, vol. \n22, no. (1), pp. 266-271, 2007. \n[23] A. Wahyuni, “Endometriosis dan infertilitas ,” Mutiara Medika, vol. 8, \nno. (1), pp. 62-71, 2008. \n \nAdvances in Health Sciences Research, volume 37\n226","source_license":"CC0","license_restricted":false}