Why me?? Etiopathology: -of Endometriosis –A nightmare for me. I was scolded by many of my  pts in 50 yrs of practice for inability to control her beningn diseases(endometriosis) . At last they all visited my granddaughters clinic who are  MD FRCS FRCOG, FACOG by the age of 6 yrs and have received several Nobel prizes for research on Corruption in India. Now they are engaged in why and How endometriosis occurs in a healthy woman?? Why & Why me?? Back to the problem of Endoemtrioms:- The main problem with endometriosis is that it cannot be imaged as easily as myoma (non-invasive procedure) but both the diseases are now considered as end result of aberrant aromatase activity leading to increase in active estrogen.

There can be aberrations in

A) Aromatase activity and that of B) 17-β-hydroxysteroid dehydrogenase type 1 and type 2 enzyme (17-β-HSD) activities.

[). Aromatase converts steroid precursors to active estrogens. Normal endometrial tissue does not exhibit aromatase enzyme activity. But it is seen in abundance in leiomyoma-- 90% cases.]

 In endometriosis: - 1) Aberrant aromatase activity and 2) Deficiency of 17-β-HSD (type 2) (in normal endometrial this enzyme converts active estrogen to inactive estrogen form)

In Myoma: There is increased activity of17-β-HSD type 1--so inactive estrogen is converted more into active estrogens. There is reversal of activity of 17-β-HSD so that more active oestrogen is formed. This leads to increased uterine peristalsis- interfering with nidation. If we believe that genetic cause and resultant enzyme disorder is the prime cause of myoma and endometriosis then medical treatment may be answer in near future. GENE THERAPY/

Does myomectomy procedure increase fecundity? - No.

But does laparoscopic try of endometriosis increase fecundity? - Yes.

But both forms of surgery (myomectomy and chocolate cyst) – decreases preg compl and increase pregnancy outcome.

Medical TR (GnRH agonist/Aromatase inhibitors either alone or concomitantly) therefore will take care both myoma and associated endometriosis.

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So far as pregnancy outcome is concerned: Role of surgery in submucous myoma is obvious but benefits in cases of Subserous and submucus myoma is doubtful.

Myomectomy should  only be contemplated in cases with  Subserous and submucus myoma if no  other demonstrable cause for RSA.

For Recurrent abortion: Role of Myoma with associated Endometriosis should be considered.

And modest benefit of myomectomy only- counsel regarding risk/benefit profile.

In 10% of all RSA there will be distortion of uterine cavities which mw be due to myoma, endometriosis, polyps, IUA (Intra-uterine adhesions).

Submucus myoma are of type 0= absolutely pdunculated, Type I= less than 50% is intramural and mostly hanging in cavity and Type II= above 50% of volume of myoma is within the substance of uterus. These cause (fibroids) cause distortion of endometrial cavity

Subserous= ≥ 50% is outside the substance of uterus.