Endometriosis and Adenomyosis

ENDOMETRIOSIS
• Endometriosis is defined as the presence of endometrial

tissues at other sites other than the uterine
endometrium.
• Endometrial tissues are oestrogen and progesterone
sensitive tissue
• They are usually found within the peritoneal cavity,
predominantly within the pelvis and commonly on the
uterosacral ligaments.
• It can also be found in other sites such as the umbilicus,
abdominal scars, nasal passages, and pleural cavity.
• The condition is predominantly found in women of
reproductive age of all races and social strata.
• Endometriotic tissue responds to cyclical hormonal changes
and therefore undergoes cyclical bleeding and causes local
inflammatory reactions.
• Repeated bleeding, inflammation, and healing lead to
fibrosis.
• This cyclical damage causes adhesions between associated
organs causing chronic pain and infertility
Incidence
• Affects approximately 1–2 percent of women of
reproductive age.
• It is the most common benign gynaecological condition,
present 10-15% of all women.
• Seen in 30-40% of women with a history of infertility
• Also, in 70-85% of women with chronic pelvic pain
• No racial predisposition
• Has familial association- risk is increased 10x if first
degree relations are affected
Aetiology
• Aetiology is unknown
• Although there have been many theories, no single theory
adequately explains the pathogenesis in all cases.
Theories
• Retrograde menstruation (Sampson)
• Haematogeneous or lymphatic spread (Halban)
• Coelomic metaplasia (Meyer/Novack)
• Immunological defects (Dmowski)
• Genetic predisposition
• Iatrogenic
Clinical symptoms
• Classical clinical features are severe cyclical, non-colicky pelvic
pain around the time of menstruation, sometimes with
menorrhagia.
• Symptoms may begin a few days before menses and last till the
end of menses.
• Usually, there is a lack of correlation between extent of disease
and the intensity of symptoms.
• Deep pain with intercourse (deep dyspareunia) can also indicate
the presence of endometriosis in the pouch of Douglas.
• Symptoms of ovarian accidents from endometrioma (chocolate
cyst)
• Infertility
• Back pain
Other site specific symptoms
• Urinary tract- cyclical haematuria/dysuria, ureteric
obstruction
• Nose- cyclical epistaxis
• Lungs-cyclical haemoptysis, haemopneumothorax
• Gastrointestinal tract- dyschezia (pain on defecation),
cyclical rectal bleeding, intestinal obstruction.
-Pelvic colicky pain throughout the menstrual cycle may
be associated with irritable bowel syndrome
• Peritoneal cavity- haemorrhagic ascites
• Umbilicus/Surgical scar- cyclical pain and bleeding
Diagnosis
• History of cyclical abdominal or other sites pain
• Cyclical bleeding or other symptoms exacerbation at other
sites
• History of chronic pelvic pain
• History of infertility
• Bimanual pelvic examination
-thickening or nodularity of the uterosacral ligaments
-tenderness in the pouch of Douglas
-an adnexal mass
-fixed retroverted uterus
Investigations
• Transvaginal USS- can detect gross endometriosis involving
the ovaries (endometriomas or chocolate cysts), USS
cannot detect smaller lesions
• MRI- can detect endometriosis >5mm in deep tissues
• Laparoscopy- is the gold standard for the diagnosis of
abomino-pelvic endometriosis (endometriotic lesions can
be red, puckered, black ‘matchstick’ or white fibrous
lesions)
• Laparoscopy also affords the advantage of concurrent
surgical diathermy and/or excision of the endometriotic
lesions and staging of the disease.
Staging of endometriosis (ASRM)
Classification is based on the number, location, depth of
implants and presence of filmy or dense adhesions
It uses the point system to quantify endometriotic lesions
• Minimal (stage 1)- there are a few small superficial implants
(1-5)
• Mild (stage 2)- there are more and deeper implants than in
stage 1(6-15)
• Moderate (stage 3)-there are many deep implants, small cysts
in one or both ovaries, presence of filmy adhesions (16-40)
• Severe (stage )4- there are widespread deep implants, large
cysts in one or both ovaries, many dense adhesions (>40)
NB: the severity or the score does not necessarily correlate
with the level of pain or presence of other symptoms.
Management
• Patients with endometriosis are often difficult to treat
because of associated psychological issues.
• It is a recurrent disorder throughout the whole of
reproductive life and it is impossible to guarantee
complete cure.
• Treatment should therefore be tailored for the individual
according to her age, symptoms, extent of the disease
and her desire for future childbearing.
• Treatment may be medical, surgical and sometimes
combined.
Medical therapy
• NSAIDS- reduces the severity of dysmenorrhea and
pelvic pain, used only for symptom control.
• Combined oral contraceptive agents- COC should be
prescribed to be taken continuously for an initial six
month period, to render the patient amenorrhoeic. If
there is symptomatic relief with the continuous use of
COC, then this therapy should be continued indefinitely
until pregnancy is intended.
• Progestogens- in patients with contraindications for COC
progestogens can be used e.g Cerazette or
Medroxyprogesterone acetate or LNG-IUS. They induce
amenorrhea and alleviate symptoms of endometriosis. The use
LNG-IUS has been shown to be effective in achieving a long-term
therapeutic effect.
• Danazol/Gestrinone- these are synthetic androgens that
suppress ovarian function. Although effective, the androgenic
side effects such weight gain, greasy skin and acne over long
term use (>six months), alterations in lipid profiles or liver
function, limit their use.
• Gonadotrophin-releasing hormone agonists (GnRH-A)-These
drugs induce a state of hypogonadotrophic hypogonadism or
pseudo-menopause with low circulating levels of oestrogen.
Side effects include symptoms of menopause, in particular hot
flushes and night sweats.
Surgical treatment
• Conservative surgery
-Laparoscopy is the standard surgery it involves the use of
diathermy, laser vaporization or excision of endometriosis.
Endometriotic cysts should not just be drained but the
inner cyst lining should be excised or enucleated.
• Definitive surgery-in the presence of severe symptoms or
progressive disease or in women who have completed
their families, hysterectomy and bilateral salpingo-
oophorectomy is curative. The removal of the ovaries is
essential in achieving cure.
Adenomyosis
• Adenomyosis is a disorder in which endometrial glands
are found deep within the myometrium.
• Patients with adenomyosis are usually multiparous and
diagnosed in their late thirties or early forties.
• They present with increasingly severe secondary
dysmenorrhoea and increased menstrual blood loss
(menorrhagia).
• Examination may be useful with the findings most often
of a bulky and sometimes tender globular uterus
perimenstrually.
• Diagnosis is usually confused with uterine fibroids
• Ultrasound examination of the uterus shows haemorrhage
filled, distended endometrial glands. Sometimes this appears
like irregular nodule mimicking uterine fibroids.
• MRI is a more definitive investigation of choice as it provides
excellent images of the myometrium, endometrium and areas
of adenomyosis.
• Given the difficulty associated with preoperative diagnosis of
this condition, medical and conservative treatments are poorly
developed.
• However, any treatment that causes amenorrhoea will reduce
the symptoms.
• Definitive treatment is hysterectomy.

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ENDOMETRIOSIS

• Endometriosis is defined as the presence of endometrial

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