Clinical Manifestation and Anatomical Location of Endometriosis Based on the Diagnostic Laparoscopic Result

of the diagnostic laparoscopy at Obstetrics and gynecology polyclinic Dr. Hasan Sadikin Bandung for the period 2016-2018. A. Ethiopathogenesis The retrograde menstruation theory was developed by Sampson in 1927. This was confirmed by a laparoscopic examination which proved that there was a reverse flow of menstrual blood that flowed back through the tube into the pelvic cavity (retrograde). Based on this theory, endometriosis is a consequence of the backflow of menstrual blood through the fallopian tubes, which continues with implantation and growth in the peritoneum and ovaries [7]. Lymphatic and vascular embolism theory explains the mechanism of endometriosis in the outer regions pelvis. The retroperitoneal area has a lot of lymphatic circulation. A study showed that 29% of women suffering from endometriosis was found lymph nodules in the pelvis. In addition, the spread of adenocarcinoma via the lymphatic route supports the theory that endometriosis can spread via the lymphatic route [7]. Coelomic Metaplasia Theory was put forward by Robert Meyer, who stated that endometriosis occurs due to certain Advances in Health Sciences Research, volume 37 Proceedings of the 12th Annual Scientific Meeting, Medical Faculty, Universitas Jenderal Achmad Yani, International Symposium on "Emergency Preparedness and Disaster Response during COVID 19 Pandemic" (ASMC 2021) Clinical Manifestation and Anatomical Location of Endometriosis Based on the Diagnostic Laparoscopic

(From Obstetric and Gynecology Policlinic RSUP Dr. Hasan Sadikin Bandung within 2016-2018) Copyright © 2021 The Authors. Published by Atlantis Press International B.V. This is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 222 stimulation, were to be dominantly coming from hormone within parietal peritoneum cell which is a pluripotent tissue [7]. Immunologic and genetic theory were to seen as immune disorders occur in women who suffer from endometriosis. A study found a failure in the system for collecting and removing waste substances during menstruation by macrophages and decreased Natural Killer (NK) cell function in endometriosis. Several studies have found an increase in Immunoglobulin A (IgA), IgG and IgM in the pe ritoneal serum of patients with endometriosis [7]. B. Anatomical Location and Manifestation of Endometriosis Most commonly, endometriosis is found in the pelvic area. The ovaries, pelvic peritoneum, anterior and posterior cul - desac, and uterosacral ligaments are also frequently involved. In addition, it can be fo und in the rectovaginal septum, ureters and bladder. The clinical symptoms of endometriosis will peak in the premenstrual state, then sub side after menstruation is over [7]. Pelvic pain is the most common symptom. Other symptoms are dysmenorrhea, pain in t he bladder or dysuri a, dyspareunia, dyschezia, and s ome patients even present with complaints of infertility [10,11]. C. Risk Factors Genetics as a risk factor was studied in the Oxford Endometriosis Gene (OXEGENE) study, an international collaborative project that has attempted to identify the locus of vulnerability using linkage analysis. Which is significant on chromosome 10q26. Chromosome 10q26 has previously been involved in gene studies, and the results reported aberrant endometrial EMX2 expression in women with endomet riosis. EMX2 itself plays a role in coding the transcription factors needed in the development of the reproductive tract. But to date, there are no official studies that confirm whether EMX2 contributes or not to the development of endometriosis [12,13]. Meanwhile, women whose mothers or sisters have endometriosis have a seven times greater risk of experiencing endometriosis. The incidence of endometriosis is 10 -20% in women of reproductive age, rarely occurs at th e age of premenars or menopause [14]. Women w ith short menstrual cycles can increase the risk of exposure to menstruation which will have an increased risk of retrograde menstruation/reflux, making it easier for endometriosis. This shortening of the menstrual cycle increases the hormone estrogen expo sure compared to women who have long menstrual cycles [15]. The development and growth of endometriosis tissue depend on sex steroid hormones and local growth factors such as insulin-like growth factor 1 (IGF -1) or vascular endothelial growth factor (VEGF). Estrogen increases sharply in the short time before ovulation; estrogen itself has a synergistic effect with IGF-1 / VEGF and sometimes actually enhances the effect of IGF -1 / VEGF on the proliferation and mitosis of ectopic endometrial cells, which will result in the formation of endometriosis [16]. During the menstrual cycle of patients with endometriosis, cyclic bleeding can occur in the nasal cavity, which occurs due to the presence of estrogen receptors on the mucosal surface of the respiratory tract; this can occur due to an imbalance in the secretion of matrix metalloproteases (MMPs) and tissue inhibitor of metalloproteases (TIMPs) [17]. D. Diagnosing Endometriosis The physical examination of endometriosis begins with an inspection of the using a speculum, followed by bimanual examination and palpation of the rectovagina. Examination during menstruation can increase the chances of detecting endometriosis nodules and also assess pain [7,18]. Ultrasound is used as the first -line examination performed on patients where the pelvic di sease is suspected. Ultrasound has good resolution, easy accessibility, is inexpensive, and free from radiation. Although ultrasound has limitations for diagnosing peritoneal endometriosis, it is very effective in diagnosing endometrioma. MRI is a good alt ernative non-invasive diagnostic method where the entire pelvic state can be visualized with high specificity and sensitivity, especially for detecting deep infiltrating endometriosis / deep nodular endometriosis and endometrioma. The disadvantage of MRI i s its inability to detect small (<3mm) peritoneal lesions [10]. Laparoscopy is the main method or gold standard used to diagnose endometriosis. Laparoscopic findings that were seen were discrete endometriosis lesions, endometrioma, and adhesions formation. The examination is carried out during the menstrual cycle in the proliferative phase until the early secretory phase so that endometriosis can be visualized properly. Operative laparoscopy requires three basic components, namely skills, equipment, instrume nts, operating room facilities, and an operating team trained. Its advantages are minimal bleeding, a high degree of operative precision, low complications, short treatment time, and minimal surgical wounds [7,8,19]. II. RESEARCH METHODS This research method is descriptive research. This study used secondary data, namely the medical records of endometriosis patients with clinical symptoms and the results of laparoscopy at the Obstetrics and Gynecology Polyclinic of Dr. Hasan Sadikin Bandung for the period 2016 -2018. From 417 medical records of p atients with a diagnosis of Endometriosis, the study sample was selected. It was obtained 220 medical records of patients diagnosed with Endometriosis, which performed diagnostic laparoscopy in accordance with the inclusion and exclusion criteria, then the number of samples in this study was 100 samples using the simple random sampling method. The variables in this study were age, parity, clinical features, and anatomical location. Advances in Health Sciences Research, volume 37 223 III. RESULTS AND DISCUSSION A. Description of Age Characteristics of Endometriosis Patients in Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung within 2016-2018 TABLE I. DESCRIPTION OF THE CHARACTERISTICS OF ENDOMETRIOSIS PATIENTS BY AGE Age (year) n % 20-24 23 23 25-29 20 20 30-34 28 28 35-39 17 17 40-44 12 12 45-49 0 0 Total 100 100 Based on Table 1 the description of age within 100 endometriosis patient group found that the age of endometriosis patients at the Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung for the period 2016 - 2018 were mostly in the age range 30 -34 years with a total of 28 people (28%) [20]. This study's results are almost the same as research conducted by Hestiantoro et al. shows that the largest age group is 30 -34 years (29.72%). The results of this study indicate that endometriosis in women of reproductive age will have a greater effect on the quality of life of these patients. Therefore, early case find ings will reduce serious complications so as not to affec t the patient's quality of life [21]. B. Description of Parity Characteristics of Endometriosis Patients in Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung Period 2016-2018 TABLE II. CHARACTERISTICS OF PARITY WITHIN ENDOMETRIOSIS Parity n % Nullipara (P0) 73 73 Primipara (P1) 19 19 Multipara (P2) 3 8 Total 100 100 From what we could see from Table 2, shows that the most endometriosis patients were to be dominantly nulliparous, with a total of 73 people (73%). The results of this study are in accordance with research conducted by A badi, which was found to be almost the same, showing that 46% of patients were nulliparous. Research conducted by Rajuddin and Jacoeb is also in line with the results of this study which found 26 cases (81.3%) were to be nulliparous. Based on several clinical and epidemiological research data results, there is an indication of a relationship between a history of parity and a risk factor for endometriosis [21]. C. Overview of Clinical Symptoms of Endometriosis Patients in Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung Period 2016-2018 TABLE III. DESCRIPTION OF CLINICAL SYMPTOMS OF PREDOMINANT COMPLAINTS WITHIN ENDOMETRIOSIS PATIENTS Chief Complaint n % Dysmenorrhea 74 74 Infertility 20 20 Pelvic Pain 5 5 Dyspareunia 1 1 Disuria 0 0 Dyskezia 0 0 Total 100 100 Table 3, show that the most common complaint is dysmenorrhea, with a total of 74 people (74%). The results of this study are in accordance with research conducted by Abadi, which showed that dysmenorrhea was the most frequently complained of symptoms, namely 23 cases (70%). Another study conducted by Pangemanan et al . showed that dysmenorrhea was found in 31 cases (93.9%) [18]. The clinical symptoms felt by the patients were mostly dysmenorrhea; this is related to the role of proinflammatory cytokines that act on endometriosis lesions resulting in the production of large amounts of prostaglandin E2 (PGE2), and it may increase neuronal invasion by stimulating the formation of NGF and other neurotrophins. This results in persistent inflammatory pain and inhibits neuronal apoptosis. There was an increase in nerve fib er density in peritoneal lesions of women with endometriosis compared to women without endometriosis [22]. The data from the dysmenorrhea group were more frequent in lesions in the uterus, whereas from this study, it was found that the location of the lesi ons was mostly in the ovaries. Infertility was also found in this study, as much as 20%. Because the abnormal cell growth of endometriosis will grow along with the increase in body estrogen and progesterone levels. Endometrial tissue grows outside the uter us from the fallopian tubes infundibulum to the ovary were the most dominant location where it develops. Therefore, the ovary is the first part of the pelvic cavity to be affected by endometriosis [23]. Adhesions can also occur around the uterus and fallopian tubes. Adhesions in the uterus cause the uterus to grow retrovert, while adhesions in the fallopian tubes cause the spontaneous movement of the fimbriae's ends to carry the ovum to the uterus to be obstructed. These things cause infertility in endomet riosis. Chronic pelvic pain in endometriosis can also be caused by irritation and infiltration of the pelvic floor nerves. Chronic pelvic pain occurs when the endometriosis lesion is on the lateral wall of the pelvis. Dysuria is a symptom of endometriosis that is rarely complained of by endometriosis patients. This is based on the theory that dysuria is caused by infection. So that the diagnosis of endometriosis may be suspected if the urine culture results are negative. Dychezia is also a minor common symp tom in Advances in Health Sciences Research, volume 37 224 patients with endometriosis. Dyschezia usually reflects the presence of a rectosigmoid endometriosis implant. D. Overview of the Anatomical Location of Endometriosis Patients in the Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung Period 2016-2018 TABLE IV. OVERVIEW OF LAPAROSCOPIC RESULTS FOR ENDOMETRIOSIS PATIENTS BASED ON THE LOCATION OF THE ENDOMETRIOSIS Endometriosis location n % Ovarium 85 85 Uterus 7 7 Fallopian Tube 8 8 External Organ 0 0 Total 100 100 Table 4 shows that the anatomica l location of the most endometriosis patients is the ovary, with a total of 85 people (85%). The results of this study are in accordance with that conducted by Abadi. It was found that the largest distribution was the ovaries, as many as 27 cases (82%). Th en another study conducted by Pangemanan et al. (2007) also obtained the same results, namely from 33 endometriosis patients, 26 patients (78.8%) of whom were located in the ovary [18]. Endometriosis can occur because menstrual blood flows back through the tubes into the pelvic cavity (retrograde). So that the ovary can become the pelvic organ most often affected by the en dometriosis process [3]. Endometrial cells in the ovary can enter the bloodstream and spleen because they are influenced by hormonal cycl es, so when changes in estrogen and progesterone levels are lower or reduced, this endometrial tissue there will be necrosis and bleeding in the pelvic area. Bleeding in the pelvic area is caused by irritation of the peritoneum and ca uses dysmenorrhoea [10,13]. Endometriosis that occurs in the ovaries can form brown cysts or often refer to as brown cysts, which can cause adhesions with other organs and form a complete unity. The features of ovarian endometriosis vary, from small lesions to large cysts [10]. IV. CONCLUSION Based on research at the Obstetrics and Gynecology Polyclinic Dr. Hasan Sadikin Bandung for the 2016 -2018 period can draw conclusions (1) The characteristics of endometriosis patients based on age were mostly in the age range 30-34 years as man y as 28 people (28%), and based on the most parity nulliparous were to be dominantly found as many as 73 people (73%) (2) The most common complaint was dysmenorrhea within 74 people (74%). (3) The anatomical location of endometriosis is mostly found in the ovaries, with a total of 85 people (85%). For further research, it is also advisable to look at the types of endometriosis lesions, as well as the relationship between endometriosis and the incidence of infertility in these patients. For further research, advisable to do research with wider variables and with different data processing as it will increase the knowledge of other students about endometriosis.

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