Endometriosis &

Adenomyosis
Nur Fathinah l Syahirah Aisyah l Saiful Irfan
 Table of contents
01 02 03
Incidence of
Aetiology Clinical features
Endometriosis

04 05 06
Investigations Endometriosis &
Possible findings on physical
Infertility
examination

07 08
Adenomyosis General management
options
Endometriosis

Gynaecology 20th edition by Ten Teachers

❖ Endometrial tissue lying outside the
uterine cavity.

❖ It is not a neoplastic condition, but

malignant transformation is possible.

❖ Endometriosis tissue responds to cyclical

hormonal changes.
- undergoes cyclical bleeding & local
inflammatory reactions.
1.Ovary
2.Pouch of Douglas
(cul-de-sac)
3. Uterosacral ligament
4. Rectum
5. Fallopian tube
6.Rectovaginal septum
 01
Incidence
5 to 10% of women of
reproductive age
➢ Found in at least 1/3 of women undergoing
diagnostic laparoscopy for pelvic pain or
infertility
➢ Oestrogen dependent
 02
Aetiology
01 Sampson’s 02 Meyer’s Coelomic
Implantation Metaplasia
theory

Genetic &
03 Immunological 04 Vascular &
Factors Lymphatic spread
1 ) Sampson’s implantation theory
Retrograde menstruation transports
viable endometrial gland and tissue
within the menstrual fluid

Subsequent implantation on the

fallopian tube, ovary, peritoneal
surface etc

Women with congenital outflow tract

obstruction increase the risk
2) Meyer’s coelomic metaplasia
Metaplasia (transformation of one normal type of tissue to another
normal type of tissue)

Coelomic wall epithelium undergo metaplasia into endometrial cells &

peritoneal cells.

Peritoneal cells lining the Mullerian duct undergo differentiation back

to their primitive origin (coelomic epithelium), which then transform
into endometrial cells.

Transformation of coelomic epithelium into endometrial-type glands

may be due to hormonal stimuli or inflammatory irritation
3) Genetic & Immunological Factors
May alter susceptibility of a woman and allow her to develop
endometriosis

Increased incidence in first-degree relatives

4) Vascular & Lymphatic Spread

Embolization to distant sites has been demonstrated and explains

the rare findings of endometriosis in sites outside the peritoneal
cavity, such as the lung
 03
Clinical
Features
Classical clinical features are severe cyclical non-colicky pelvic pain
restricted to around the time of menstruation, sometimes associated
with heavy menstrual loss.

Symptoms may begin a few days before menses starts until the end of
menses.

Pelvic pain presenting with colic pain throughout the menstrual cycle
may be associated with irritable bowel syndrome symptoms.

Key indicators of the presence of endometriosis deep within the pouch

of Douglas :
1) Deep pain with intercourse (deep dyspareunia)
2) Pain on defecation (dyschezia)
 Infertility

Cyclical intestinal
Dysmenorrhea
complaint

Deep dyspareunia
Chronic pelvic pain
Symptoms of Endometriosis In Relation To Site Of Lesion

Site Symptoms

Female reproductive 1. Dysmenorrhea

tract 2. Lower abdominal and pelvic pain
3. Dyspareunia (pain with intercourse)
4. Rupture/torsion endometriosis
5. Low back pain
6. Infertility

Urinary tract 1. Cyclical Hematuria/dysuria

2. Ureteric obstruction
Site Symptoms

Gastrointestinal 1. Dyschezia (pain on defecation)

tract 2. Cyclical rectal bleeding
3. Obstruction

Surgical Cyclical pain and bleeding

scars/umbilicus

Lung 1. Cyclical hemoptysis

2. Haemopneumothorax
 03
Physical
Examination
 Vaginal Examination

Nodular feel of Fixed retroverted

uterosacral uterus
ligaments

Tenderness in the
Adnexal mass
pouch of Douglas
 4.
Endometriosis
& Infertility
Structure Possible mechanisms
Ovarian function • Luteolysis caused by prostaglandin F2
• Oocyte maturation defects
• Endocrinopathies
• Luteinized unruptured follicle syndrome
• Altered prolactin release
• Anovulation
Tubal function • Impaired fimbrial oocyte pick-up
• Altered tubal mobility
Coital function • Dyspareunia & coital dysfunction – reduced frequency
Sperm function • Antibodies causing inactivation
• Macrophage phagocytosis of spermatozoa
Early pregnancy failure • Prostaglandin induced
• Immune reaction
• Luteal phase deficiency
 5.
Endometriosis
Investigation
 Investigations

Blood: CA-125 • CA-125 are markedly elevated in cystic ovarian

endometriosis or deeply infiltrating endometriosis
• Slight increase or none, in the luteal phase of
women with minimal or mild endometriosis

Imaging: • Detect gross endometriosis or cyst associated with

• Transvaginal endometriosis (endometrioma, chocolate cyst)
ultrasound • Limited value in smaller lesion
• Detect deep infiltrating endometriosis
• MRI • Help in surgical planning
• Assess response to medical therapy
Laparoscopy • Lesions varies, can be red, puckered, black
matchstick or white fibrous lesions.

• Advantage: concurrent surgical diathermy and/or

excision of the endometriotic lesion and staging of
the disease.
 Endometriosis on Transvaginal Ultrasound

Findings include:
• Cystic lesion with ground glass appearance

• May be single or multiple

• Little or no blood flow on color Doppler

• ‘kissing’ ovaries sign:

When both ovaries
are located in
close proximity or
are touching each
other in the pouch
of Douglas
 Laparoscopic findings

Red lesion on peritoneum White fibrous lesion Black ‘matchstick lesion’

• Preferred method for diagnosis is surgical visual inspection

of pelvic organs with histologic confirmation.
• Varied appearance allows less-obvious lesions to be overlooked
Diagnosis & assessment

• Consider referral for an ultrasound or

gynecology opinion if:
- They have severe,
persistent/recurrent symptoms of
endometriosis
- They have pelvic signs of
endometriosis
- Initial management is not effective

NICE UK, endometriosis pathway

 6.
Endometriosis
management
Management
• Coexisting additional disease like irritable
bowel disease/constipation should also be
treated to improve overall success rate.
• Endometriosis is known to be a recurrent

disorder throughout the whole reproductive life

& is impossible to guarantee complete cure.

• Treatment should be tailored according to the

patient age, symptoms, extent of disease & her
desire for future childbearing.

• In most patient, disease has little proggresion.

 Clinical
Symptoms
examination Medical
persist after Laparoscopy
+ TVUSS Treatment
3-6 months
normal
 MEDICAL THERAPY
Analgesics NSAIDs
Symptomatic ↓severity of dysmenorrhea and pelvic pain
treatment
Avoid additional usage Worsened coexisting irritable bowel symptoms
of codeine/ opiates 🡪 exacerbate pelvic pain

Combined Oral Provide cycle control, ↓endometriosis associated dyspareunia,

Contraceptives contraception, cyclical dysmenorrhoea, non menstrual pain
alleviate pain
symptoms
Outco If achieves Continue therapy several years until pregnancy
mes symptomatic is intended
relief
If symptoms o Review diagnosis
persist o Treat common coexisting conditions
o Consider alternative medical or surgical
treatments
Progestogens Complement usage of COCP To induce amenorrhea
o Long acting reversible contraceptives Provide long term therapeutic
(LARCa) effect after surgical treatment
o Depot-medroxyprogesterone acetate
o Levonorgestrel Intrauterine System
(LNG-IUS/ MIRENA)
Gonadotrophin- To relieve severity and symptoms of endometriosis
releasing Available as multiple, daily o Usually administered as slow-release depot
hormone administered intranasal sprays formulations
agonists -each lasting for 1 month or more
(GnRH-a) -Avoid long term use >6 months : drug
induced osteoporosis
o Recurrence upon therapy cessation is rapid

Other hormonal Ovarian suppressive agents : o No longer use d/t newer treatment
agents Danazol and Gestrinone o Has androgenic side effects :
-Weight gain, greasy skin, acne
-Alterations lipid profile and liver function
-Potential deepening of voice

Aromatase inhibitors o Inhibit action of enzyme aromatase

o Enzyme aromatase :
-Converts androgens 🡪 oestrogens
-Overexpressed in endometriotic tissue
 SURGICAL TREATMENT
Fertility-sparing surgery
o Surgery mostly by laparoscopy

o Drainage of symptomatic endometriotic chocolate cyst + excision of inner

cyst
-To reduce risk of recurrence
-However it is associated with damage to functional ovarian tissue
-Drainage only considered as adjunct to fertility treatment

o Deposits of superficial peritoneal endometriosis : ablated or excised

during laparoscopy
-using diathermy or laser energy

o Specialist surgery :
-Treat endometriosis
+ extensive adhesions distorting normal pelvic anatomy
+ involvement other organs
+ presence of rectovaginal nodules of disease

o Recurrent risk : 30%

Hysterectomy o Removal of ovaries + all visible endometriosis
and o In women who have completed family and failed to more
oophorectomy conservative treatments

o Hormone Replacement Therapy (HRT )

a) Oestrogen-only HRT
-Started immediately following surgery up to 6 months : to
prevent activation of residual disease

b) Combined HRT
-Suppressive treatment when reactivation of new or residual
disease suspected
Adenomyosis
Presence of endometrial glands and stroma deep within
the myometrium, surrounded by reactive smooth muscle
hyperplasia
Aetiology
Strongly associated with
● Middle age group
○ Increased prevalence of risk factors by that age range and the duration of
adenomyotic development.
● Multiparous status
○ Mechanically disrupt the myometrial junctional zone by the action of the
trophoblast on the myometrium, favoring infiltration of endometrial cells
into the myometrium.
● History of gynaecologic surgery
○ Due to trauma to the uterus which may cause weaknesses within
myometrium, allowing invasion of the adjacent endometrium
Clinical features
● Secondary dysmenorrhea
○ Progressively increasing pain associated with menstruation.
Pain increases throughout menstruation, reaching its peaks
towards the later stage.
● Menorrhagia
○ Increased flow, or more frequent periods.
● Chronic pelvic pain and dyspareunia.
● Physical examination may reveal a bulky and sometimes tender
‘boggy’ uterus, particularly if examined perimenstrually.
Investigation
● Adenomyosis can only be definitively diagnosed following
histopathological examination of a hysterectomy specimen.

● Ultrasound
○ May be helpful for diagnosis when adenomyosis is particularly
localized.
○ Showing haemorrhage-filled, distended endometrial glands.
○ Sometimes may give an irregular nodular development within
the uterus, very similar to uterine fibroids.
Investigation
● MRI
○ More definitive investigation of
choice
○ Provides excellent images of
myometrium, endometrium and
areas of adenomyosis

Note the bright reflections of the central endometrium

and flecks of ectopic endometrium in the underlying
myometrium.
Management
● Due to difficulty in making diagnosis of adenomyosis
preoperatively, conservative surgery and medical treatments are
so far poorly developed.
● Any treatment that induces amenorrhea will relieve the pain and
excessive bleeding.
● On ceasing the medical treatment, symptoms will rapidly return in
most of patients
● Hysterectomy is the only definitive treatment