Endometriosis

&
Adenomyosis

Dr. Iman yousif Al-Malek

 Objectives

• Eduational Objectives:

• Understand the the history ,pathophysiology, varied

presentation, and symptoms of endometriosis.
• Understand the critical need for timely diagnosis and
effective intervention.
• Identify factors that can inform a timely and accurate
diagnosis.
• Demonstrate an ability to recommend appropriate
medical and surgical management.
 Case study 1
• A32-year-old women presents complaining of increasing pelvic pain with
her menses over the last year since she stopped her OCPs. In particular,
She has noticed more pain on her left side in the last couple of
months.She denies any changes in her blabber or bowel habits, but she
begun to have pain with deep penetration during intercourse .She started
OCPs when she was 17 for painful irregular cycles but stopped them 1 year
ago, when she got married, no history of sexual transmitted infections.On
examination ,there is no abnormal discharge but her uterus is tenderas
well as her left adnexa with a fullness that you suspect may be a mass .On
pelvic U/S she has a 5 cm cystic mass through to be an endometrioma . It
persists in repeat U/S 8 weeks later &the patient is still symptomatic.
• 1. what would be the most appropriate next step in her care ?
• 2.what is the recommended treatment if operation was done for her
through a laproscope (cystecyomy of chocalate cyst).
• 3.if you would to give her GnRH agonist, what are the side effects of it ?
 Case study 2
• A couple presents because they have been trying to conceive
for 18 months .During the interview you learn that the man
has fathered a child in a previous marriage and is in a good
health .The women is 28 years and reported that she has had
painful menses for the past 5 or 6 years.
• 1. If you suspect that the women has an endometriosis .What
are the information in the history that increase your
suspension?
• 2.During ex. What are the positive findings that going with
endometriosis .
• 3.what are the percentage of endometriosis ?
 Study case 3
• A 46-year-old G2P2 obese women is refered from the primary care
physician because of increasinglyheavy &painful menses over the last 18
months . She has tried an OCPs with some improvement of her bleeding
but no improvement in her pain. She reports no other history of pelvic
pain or abnormal bleeding in the past. She has never had an abnormal Pap
smear &states she has never had any infections, Her only medical
problems are her obesity , hypertension,& gastroesophagial reflex
disease.On exam., you note normal external genetalia, vagina, & cervix.
However, her uterus is slightly enlarged ,mildly tender, and softer than you
expected. She has noadnexal mass or tenderness.
• 1.What is the most common diagnosis ? Most common investigations?
• 2.what are the studies you need to reach your diagnosis ?
• 3. What are the investigations you need if you decide to do for her
Hysterectomy?
 Sites of Endometriosis
• Women with endometriosis have patches of “normal”
endometrium located outside of the uterus. The most
common locations for these implants are on the:
• Ovary
• Anterior and posterior cul-de-sac
• Posterior broad ligament
• Uterosacral ligament
• Uterus
• Fallopian tube
• Sigmoid colon
• Appendix
• Round ligament
• However, endometriosis can be found virtually anywhere in
the body, including sites quite remote from the pelvis, such
as lung, vertebra, and skin.
 What is endometriosis?
• Endometriosis (from endo, "inside", and metra, "womb") is a
common gynecologic problem in women that is characterized
by growth beyond or outside the uterus of tissue resembling
endometrium, the tissue that normally lines the uterus.

Endometriosis is typically seen during the reproductive years;

it has been estimated that it occurs in roughly 10% to 15% of
women. Its main but not universal symptom is pelvic pain in
various manifestations; further, endometriosis is a common
finding in women with infertility, as 30% to 40%.

• Endometrial implants, while they can cause problems, are

benign (not cancerous).
 Prevalence
• Endometriosis affects women in their reproductive years. The exact
prevalence of endometriosis is not known, since many women may
have the condition and have no symptoms.
• Endometriosis is estimated to affect over one million women
(estimates range from 3% to 18% of women) in the United States. It
is one of the leading causes of pelvic pain and reasons for
laparoscopic surgery and hysterectomy in this country.
• While most cases of endometriosis are diagnosed in women aged
around 25-35 years, endometriosis has been reported in girls as
young as 11 years of age.
• Endometriosis is rare in postmenopausal women. Endometriosis is
more commonly found in white women as compared with African
American and Asian women.
• Studies further suggest that endometriosis is most common in
taller, thin women with a low body mass index (BMI). Delaying
pregnancy until an older age is also believed to increase the risk of
developing endometriosis.
 What causes endometriosis?
*The cause of endometriosis is unknown. One theory is that the endometrial tissue is
deposited in unusual locations by the* backing up of menstrual flow into the Fallopian
tubes and the pelvic and abdominal cavity during menstruation (termed retrograde
menstruation). The cause of retrograde menstruation is not clearly understood. But
retrograde menstruation cannot be the sole cause of endometriosis. Many women have
retrograde menstruation in varying degrees, yet not all of them develop endometriosis.

Another possibility is that areas* lining the pelvic organs possess primitive cells that are
able to grow into other forms of tissue, such as endometrial cells. (This process is
termed coelomic metaplasia.)

It is also likely that direct transfer of endometrial tissues *during surgery may be
responsible for the endometriosis implants sometimes seen in surgical scars (for
example, episiotomy or Cesarean section scars). Transfer of endometrial cells via the
bloodstream or lymphatic system is the most likely explanation for the rare cases of
endometriosis that develop in the lung & brain and other organs distant from the pelvis.

Finally, some studies have shown alternations in the* immune response in women with
endometriosis, which may affect the body's natural ability to recognize and destroy any
misdirected growth of endometrial tissue.
 Symptoms
• A major symptom of endometriosis is severe recurring pelvic pain. The
amount of pain a woman feels is not necessarily related to the extent or
stage (1 through 4) of endometriosis. Some women will have little or no
pain despite having extensive endometriosis affecting large areas or
having endometriosis with scarring. On the other hand, women may have
severe pain even though they have only a few small areas of
endometriosis. Symptoms of endometriosic-related pain may include:
• dysmenorrhea - Painful, sometimes disabling menstrual cramps; pain may
get worse over time (progressive pain) also lower back pains linked to the
pelvis.
• Chronic pelvic pain - typically accompanied by lower back pain and/or
abdominal pain.
• dyspareunia - Painful sex/deep dyspareunea.
• dyschezia - Painful bowel movements.
• dysuria - Urinary urgency, frequency, and sometimes painful voiding.
• Infertility
Many women with infertility have endometriosis.
• As endometriosis can lead to anatomical distortions and adhesions
the causality may be easy to understand, however the link between
infertility and endometriosis remains enigmatic when the extent of
endometriosis is limited.

• It has been suggested that endometriotic lesions release factors

which are detrimental to gametes or embryos, or, alternatively,
endometriosis may more likely develop in women who fail to
conceive for other reasons and thus be a secondary phenomenon;
for this reason it is preferable to speak of endometriosis-associated
infertility in such cases.

*In general the symptom depend on the site of endometriosis.

 Other symptoms may be present, including:

• Nausea, vomiting, and/or diarrhea - particularly just prior

or during the period.
• Frequent menses flow or short menstrual cycle.
• Heavy and/or long menstrual periods.
• Some women may also suffer mood swings and fatigue.
• In addition, women who are diagnosed with endometriosis
may have gastrointestinal symptoms that may mimic
irritable bowel syndrome.
*Patients who rupture an endometriotic cyst (chocolate
cyst) may present with an acute abdomen as a medical
emergency.
 Treatments
• While there is no cure for endometriosis, in many patients menopause
(natural or surgical) will abate the process.
• In patients in the reproductive years, endometriosis is simply managed:
the goal is:
*to provide pain relief, * to restrict progression of the process,
* and to relieve infertility if that should be an issue.

In younger women with unfulfilled reproductive potential, surgical

treatment tends to be conservative, with the goal of removing
endometrial tissue and preserving the ovaries without damaging normal
tissue.
In women who do not have need to maintain their reproductive potential,
hysterectomy and/or removal of the ovaries may be an option; however,
this will not guarantee that the endometriosis and/or the symptoms of
endometriosis will not come back, and surgery may induce adhesions
which can lead to complications.
• In general, patients are diagnosed with endometriosis at time of surgery,
at which time ablative steps can be taken. Further steps depend on
circumstances: patients without infertility can be managed with:
*hormonal medication that suppress the natural cycle and pain
medication, while infertile patients may be treated* expectantly after
surgery, *with fertility medication, or *-with IVF.
•
Sonography is a method to monitor recurrence of endometriomas during
treatments.

It is suggested, but unproven, that pregnancy and childbirth can cease the
growth of endometriosis.[citation needed]. Nevertheless, after the
pregnancy, there is no guarantee that the endometriosis will not recur.
• Treament :either surgery or medication.
• Surgery:
Although medicine is extensively used for this condition, the most
effective treatment is surgical :
The approach can be either by laparoscopy or laparotomy.
• Conservative therapy is usually applied in women where the reproductive
potential needs to be maintained and consists of removal or ablation of
endometriosis, adhesions, resection of endometriomas, and restoration of
normal pelvic anatomy as much as is possible. It is important to preserve
healthy ovarian tissue as much as possible. however as laparoscopy is
already used to diagnose endometriosis the surgical correction can often
be performed at the same session. Further, laparoscopy has a faster
recovery time and involves less hospitalization. Laparoscopic removal or
ablation of endometriosis in minimal or mild endometriosis has been
shown to be equal or better then expectant management, medical
therapy, or surgery via laparotomy.[
 2nd type of surgery
• Radical therapy in endometriosis removes the uterus (Hysterectomy) and tubes
and ovaries (bilateral salpingo-oophorectomy). Modifications of this approach
involve preserving a healthy appearing ovary, however, this will increase the risk of
recurrence. Radical surgery is generally reserved for women with chronic pelvic
pain that is disabling and treatment-resistant. Not all patients with radical sugery
will become pain-free. The history of endometriosis is not a contraindication to the
use of hormone replacement therapy as the estrogen dose in HRT is low.
For patients with extreme pain, a presacral neurectomy may be indicated where
the nerves to the uterus are cut. However, strong clinical evidence showed that
presacral neurectomy is more effective in pain relief if the pelvic pain is midline
concentrated, and not as effective if the pain extends to the left and right lower
quadrants of the abdomen. This is due to the fact that the nerves to be transected
in the procedure are innervating the central or the midline region in the female
pelvis. Furthermore, women who had presacral neurectomy have higher
prevalence of chronic constipation not responding well to medication treatment
because of the potential injury to the parasympathetic nerve in the vicinity during
the procedure.
• Treatments for endometriosis in women who do not wish to become
• pregnant include:

• Medication
*NSAIDs not only reduce pain but also reduce menstrual flow. They are
commonly used in conjunction with other therapy. For more severe cases
narcotic prescription drugs may be used.
*Progesterone or Progestins: Progesterone counteracts estrogen and
inhibits the growth of the endometrium. Such therapy can reduce or
eliminate menstruation in a controlled and reversible fashion. Progestins
are chemical variants of natural progesterone.
 Types of medication
*Oral contraceptives reduce the menstrual pain associated with endometriosis.
They may function by reducing or eliminating menstrual flow and providing
estrogen support. Typically, it is a long-term approach.

*Danazol (Danocrine) and gestrinone are suppressive steroids with some

androgenic activity. Both agents inhibit the growth of endometriosis but their use
remains limited as they may cause hirsutism.

*Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by

increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results
in down regulation, inducing a profound hypoestrogenism by decreasing FSH and
LH levels. While quite effective, they induce unpleasant menopausal symptoms,
and over time may lead to osteoporosis.
Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in the
woman's body to prevent or reduce growth of endometriosis. The injection is
given in 2 different doses a once a month for 3 month, shot with the dosage of
(11.25mg) or a once a month for 6 month shot with the dosage of (3.75mg).

* Aromatase inhibitors are medications that block the formation of estrogen and
have become of interest for researchers who are treating endometriosis.
 Adenomyosis
• Adenomyosis uteri is defined by the presence ofendometrium within the
myometrium.

• Adenomyosis uteri can involve the whole muscle thickness down to the
serosa and can be either‘focal’ or ‘diffuse’. In diffuse adenomyosis uteri,
the uterus becomes enlarged and globular.

• Associated pathology:
Up to 80% of women with adenomyosis also have other lesions, the most
frequent being leiomyomas.
Endometrial polyps, hyperplasia (with and without atypia) and
adenocarcinoma are more frequent in women with adenomyosis.
 Prevalence & Symptoms

• The majority of cases are reported in women aged 40–50 years and there
is a positive association with parity. Adenomyosis occurs relatively
frequently in pregnancy, and was diagnosed using MRI.

• There is no relation to age at first childbirth and prior caesarean section

The majority of cases are reported in women aged 40–50 years and there
is a positive association with parity.
 Menstrual disorders:
• About 35% of women with adenomyosis uteri are asymptomatic.
Symptomatic women mostly resent with menorrhagia (40–50%),
dysmenorrhoea (10–30%) and metrorrhagia
• (10–12%) and, occasionally, dyspareunia .

• Menorrhagia or Heavy menstrual bleeding may be due to dysfunctional

contractility of the myometrium.

• Mefenamic acid administration can reduce blood loss, suggesting that

prostaglandins may be involved.

• Other factors that may be involved are anovulation or endometrial

hyperplasia. The extent and spread of adenomyosis uteri may correlate
with pelvic pain and dysmenorrhea and, to a lesser degree, with
menorrhagia and dyspareunia.
 Treatment of Adenomyosis
• Different surgical and medical modalities of treatment have been
addressed in the literature but many of these have not been tested
specifically for adenomyosis uteri.
• Medical:
• Non-hormonal therapy, including mefenamic and tranexamic acid,
may be effective for the symptomatic relief of menorrhagia
associated with uterine adenomyosis

• Low-dose, continuous combined oral contraceptives wit withdrawal

bleeds every 4–6 months may be effective in relieving menorrhagia
and dysmenorrhoea.
• GnRH analogues have also been used in the treatment of adenomyosis
uteri.They reduce uterine volume and result in symptomatic relief but
their use is limited because of skeletal and general swide effects.

• The use of danazol has largely been superseded because of its side-effects. A
more recently-developed danazol-loaded intrauterine device is used.

• The levonorgestrel-releasing intrauterine system has also been successfully

used for adenomyosis-associated menorrhagia.

• Mifepristone (RU486) has been used for the treatment of endometriosis.

Long-term, low-dose mifepristone causes anovulation, a reduction in
painful symptoms and improved endometriosis.

• GnRH agonist in a woman with severe symptomatic uterine adenomyosis.

Surgical treatment of Adenomyosis
• Laparoscopic myometrial electrocoagulation induces localised coagulation
and necrosis ofadenomyosis uteri.

• Endomyometrial ablation or resection may be an option for women with

superficial disease complaining of menorrhagia but, clearly, desire for
a future pregnancy is a contraindication.

• Reduction of the uterine blood flow by uterine artery embolisation has

been shown to reduce the symptoms associated with adenomyosis uteri
and to improve the quality of life.

• Furthermore, there is a risk of emergency hysterectomy for

uncontrollable bleeding during the procedure, as well as a high incidence
of adhesion formation following the procedure.Although not
recommended, this technique may be best suited for women more than
40 years of age who have completed their families.