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John Sampson-now known as the "father of endometriosis"-described a series of perforating hemorrhagic ovarian cysts he called "chocolate cysts," coining the term "endometriosis" to describe the peritoneal implants he first envisioned as seedlings derived from disease in the ovary.3 In addition to naming the gynecologic disorder (endometriosis), he also proposed the theory of retrograde menstruation as the pathogenesis of this disorder/ His 1927 publication was one of the most influential and remains the prevailing teaching regarding the theory of endometriosis.
Whereas neural inflammation or invasion might explain the pain of women with deep infiltrating endometriosis, it cannot be the mechanism that produces pain in women wrho have superficial peritoneal/ovarian disease.3" The pain associated with mild disease more likely relates to inflammation resulting from cyclic focal bleeding in and around peritoneal implants or from the actions of inflammatory cytokines released by the larger numbers of macrophages and other immune cells in the peritoneal fluid of women with endometriosis.
Like transvaginal ultrasonography, magnetic resonance imaging (MRI) can be helpful in the detection and differentiation of ovarian endometriomas from other cystic ovarian masses, but cannot reliably image small peritonea) lesions.358,,w"'81 For detection of peritoneal implants, MR] is superior to transvaginal ultrasonography but still identifies only 30-40% of the lesions observed at surgery.
The classic peritoneal implant is a blue-black "powder- burn" lesion (containing hemosiderin deposits from entrapped blood) with varying amounts o!
• Transvaginal ultrasonography and MRI are both highly sensitive and specific for detection of ovarian endometriomas but cannot reliably image peritoneal implants of disease.
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