endoadeno_final

Endometriosis and
Adenomyosis
“Presence of endometrial tissue other than the
lining of endometrial cavity’’
Common in reproductive age 1-2 %
Most common benign gynaecological condition,

it is oestrogen depend and its resolve after
menopause.
Commonly occur in pelvic
• Ovaries
• Uterosacral ligament
• Pouch of Douglas
• Lateral pelvic wall
• Ovarian fossa
Extra pelvic
• Surgical scars
• Umbilicus
• Rectum
• Pleura
• Bladder
• Endometrial tissue respond to cyclical
hormonal changes and therefore undergoes
cyclical bleeding and local inflammatory
reaction .
• Repeat bleeding and healing cause fibrosis
• This cyclical damage cause adhesion between
associated organs causing pain and infertility
Ovaries endometriomas occurs due to
accumulation of blood as a result of repeated
sheading of the endometrial surface
This blood turns brown and resemble chocolate
colour therefore called as chocolate cyst
• Endometrioma: : Part of the condition known
as endometriosis. Endometrioma is a type of
cyst formed when endometrial tissue (the
mucous membrane that makes up the inner
layer of the uterine wall) grows in the ovaries.
It affects women during the reproductive years
and may cause chronic pelvic pain associated
with menstruation.
• Endometriosis is the presence of endometrial

glands and tissue outside the uterus.
• Women with endometriosis may have
problems with fertility.
• Endometrioid cysts, often filled with dark,

reddish-brown blood, may range in size from
0.75-8 inches.
• Surgical management of endometriomas drained
laparoscopically and the cyst wall can be excised.
• In situation where the cyst wall cannt be peeled

off it can be diathermised.
• It is not recommended to use diathermy in

women who are planning to conceive bacause of
heat damage to ovaries.
Etiology of endometriosis
• Etiology is unknown
• There are several theories
1) Implantation theory
Direct implantation of endometrial tissue can
grow in the newly implanted tissue such as in
scar endometriosis
2) Retrograde menstruation (sampson’s theory)
Endometrial cells which fall with menstrual
blood into the pelvis can implant and grow in
new sites. That’s why this is common in ovaries
POD lateral pelvic wall
3)Coelomic metaplasia theory

Coelomic epithelium can undergo metaplastic
change in to endometrial tissue. This theory can
explain endometriosis in pleura and peritoneal
cavity.
4) Vascular and lymphatic spread
Vascular and lymphatic embolization of
endometrial tissue can explain occurrence of
endometriotic deposits in usual site outside the
peritoneal cavity
American Fertility Association classified
endometriosis in to 4 stage –
mild/minimal/moderate/sever base upon
How deep the peritoneal and ovarian

endometriosis is
How badly the POD is obliterate due to adhesion
How dense the adhesions are on each tube and
ovary
Symptoms
• Sever cyclic non colicky pelvic pain (pain
typically starts with or after the onset of
menses and out lasts the period .
• Dysmenorrhea
• Deep dyspareunia- due to presents of

endometrial tissues in pouch of Douglas
Pelvic pain may be associated with irritable
bowel syndrome
If distinct site affected can cause local symptoms

Cyclic epistaxis with nasal passage deposit
cyclical rectal bleeding with bowel
deposits
Physical examination
• Bimanual vaginal examination very helpful to
diagnosis
• On speculum examination
• Purplish endometriotic nodules may be visible
in the posterior fornix
• Tender nodules felt along utero-sacral
ligament
• Tender fornices and pouch of Douglas and
adnexal mass or fixed retroverted uterus.
• Sometimes palpable mass can be felt in

adnexae if there are adhesion or
endomertiomas
Investigation
• CA 125 level is raised in endometriosis
• It can be diagnosis by the TV-USS –detect

gross endometriosis involving the ovaries
(endometrioma) .In smaller USS is of limited
value
• MRI detect >5mm in size particularly in deep

tissue (rectovaginal septum)
• Laparoscopy
Gold standard of diagnosis is laparoscopy.

Typical endometriotic deposits can be seen on
laparoscopy with adjacent scarring of the tissue.
Depend on experience of laparoscopist -base on
the accuracy of visual diagnosis of endometriotic
lesion .
Lesion can be red .puckered . Black ‘matchstick’
or white fibrous lesion
a) Red lesion in b) Black ‘matchstick’
peritoneum lesions
c) White fibrous lesion
Management
• Either medical or surgical. No definitive cure is
available since the etiology of the disease is
not clearly understood yet
• Treatment should therefore be tailored for

the individual according to her age, symptoms,
extent of the disease and her desire for future
childbearing.
Medical management
Principle is to create a period of amenorrhoea
so that endometriosis tissue will undergo atropic
changes and endometriosis will undergo
regression
This can be achieved by either creating a
situation of pseudo-pregnancy or post
menopause
1) Non-steroidal anti-inflammatory drugs
(NSAIDs) are potent analgesics and are helpful in
reducing the severity of dysmenorrhoea and
pelvic pain. (The additional use codeine/opiates
should be avoided as the coexisting irritable
bowel symptoms can be worsened, exacerbating
pelvic pain symptoms)
2) Progesterone injection in high dose . Depo-

provera is usually given in a dose of 150 mg IM
every 4 weekly or continue oral tablet .use of
levonorgestrel IUD effective
3) OCP can be given continuously without the
dummy tablets so there is no breakthrough
bleeding for minimal 6 month period.
If there is symptomatic relief with the

continuous use of COC, then this therapy should
be continued indefinitely for up to several years
or even longer until pregnancy is intended.
4) Danozol which has antiestrogenic properties is
given to create post menopausal changes leading to
endometrial atrophy
There are androgenic side effects like weight
gain ,acne , hirsutism , can limit its use.
5) Gonadotrophin-releasing hormone agonists

(GnRH-A) are as effective as danazol in relieving
the severity and symptoms of endometriosis by
giving hypoestronic change
These can be administered as nasal spray or IM
depot preparation .long term therapy cause
menopausal effects like osteoporosis hot flush
and night sweating like.
The administrate low dose oestrogen therapy
(HRT) –addback is given to prevent this
Surgical management
• Conservative surgery
Laparoscopic surgery with techniques such as
diathermy , laser vaporization , or excision has
become the standard for surgical management.
In mild to minimal endometriosis purple –brown

spots can be seen in pelvis with scarring and
puckering of the adjacent tissue . These are called
‘café-au-lait spots.
• When surgery is done foe women with
subfertility adhesiolysis is performed to make
the tube and ovaries mobile .it is also
important to clear the POD of adhesion
• Patient who complaining subfertility .fertility

treatment should proceed immediately
following surgical clearance
• Aim of treatment is to make the patient
pregnant before the adhesion formation and
impair the tubal motility .so medical treatment
for endo. Not recommend after surgery .
• Since pregnancy is the nature sure for

endometriosis any women with evidence of
endometriosis should be encouraged to get
married and pregnat early
• Definitive treatment
Sever symptoms and progressive disease or in
women whose families are complete
hysterectomy and B/L salphingo –oophorectomy
which is usually curative .
HRT 6 month following surgery
Adenomyosis
• It is disorder which is endometrial gland found
deep within the myometrium ,
• Etiology yet unknown
• Patients are usually multiparous and diagnosis
in their late 30s or early 40s
• Patients are present with increasing sever
secondary dysmenorrhea and increasing
menstrual blood loss
• On examination find bulky and sometimes
tender ‘boggy’ uterus .
• USS examination of uterus may be helpful in
diagnosis –shows haemorrhage
filled ,distended endometrial glands ,some
times irregular nodules development can be
seen. (similar to fibroid )
• MRI is the more definitive investigation of
choice as it provides excellent image of
myometrium and endometrium and areas of
adenomyosis
• MRI images of adenomyosis.
• Conservative medical and surgical treatment
poorly response
• Any treatment which induce amenorrhea will
be helpful. –relive pain and excessive bleeding
• symptoms rapidly return in the majority of
patients, and hysterectomy remains the only
definitive treatment.

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Endometriosis and

Common in reproductive age 1-2 %

Most common benign gynaecological condition,

• Endometriosis is the presence of endometrial

• Endometrioid cysts, often filled with dark,

• In situation where the cyst wall cannt be peeled

• It is not recommended to use diathermy in

3)Coelomic metaplasia theory

How deep the peritoneal and ovarian

• Deep dyspareunia- due to presents of

If distinct site affected can cause local symptoms

• Sometimes palpable mass can be felt in

• It can be diagnosis by the TV-USS –detect

• MRI detect >5mm in size particularly in deep

Gold standard of diagnosis is laparoscopy.

• Treatment should therefore be tailored for

2) Progesterone injection in high dose . Depo-

If there is symptomatic relief with the

5) Gonadotrophin-releasing hormone agonists

In mild to minimal endometriosis purple –brown

• Patient who complaining subfertility .fertility

• Since pregnancy is the nature sure for

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