Endometriosis

Adenomyosis
Salfarina Azira
112015200
dr. Johanes Benarto SpOG

FK UKRIDA KEPANITERAAN KLNIIK ILMU KEBIDANAN

RSUD CENGKARENG
PERIODE 13 Feb -22 April 2017

Endometriosis
 Introduction

the presence of endometrial glands and

stroma tissue outside the uterus (other
than uterine mucosa)
primarily on the pelvic peritoneum,
ovaries, and rectovaginal septum, and in
rare cases on the diaphragm, pleura, and
pericardium1

1. Journal of Obstetrics and Gynaecology Canada, Volume 32,

Number 7, Endometriosis, Diagnosis and Management, 2010
 Incidence and Prevelance

affects 6 to 10% of women of

reproductive age, 50 to 60% of women
and teenage girls with pelvic pain, and up
to 50% of women with infertility.2,3
highest incidence of endometriosis is in
women who undergo laparoscopic
assessment of infertility or pelvic pain,
endometriosis will be diagnosed in 20%
to 50%.
2.Goldstein DP, deCholnoky C, Emans SJ, Leventhal JM. Laparoscopy
in the diagnosis and management of pelvic pain in adolescents. J
Reprod Med 1980;24:251- 6.
3. Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet
 High risk women5:
1. 3 to 10 times greater among first-degree relatives
of women with this disease
2. anomalous reproductive tracts and resultant
obstruction of menstrual outflow
3. nulliparity, subfertility, and prolonged intervals
since pregnancy

5. Wheeler JM. Epidemiology and prevalence of endometriosis.

Infertil Reprod Med Clin North Am 1992;3:5459.
 Etiology and Pathogenesis

Transplantation - Sampson (1927)

postulated that during menstruation, vital
endometrium is transported backwards
via the Fallopian tubes into the small
pelvis and implants there.
mechanisms of apoptosis are disrupted in
the small pelvis and desquamated
endometrium has undergone pathological
change6

6. Sampson JA. Peritoneal endometriosis due to menstrual

dissemination of endometrial tissue into peritoneal cavity. Am J
 Coelomic Metaplasia cells can
develop and differentiate in situ to
become endometrioid tissue structures
based on the complex and complete
information contained in the genome of
each cell (same embryogenic precursor)
Infectious influences, hormonal
imbalances or immunological disorders
can induce such metaplastic processes

7. K.-W. Schweppe1, T. Rabe2 (DGGEF e.V.), M. Langhardt1, J.

Woziwodzki1, F. Petraglia3 (EEL), L. Kiesel4 (SEF) Endometriosis
 Stem cell concept - corresponds to a
combination of the transplantation and
the metaplasia theories.
By using surface markers, cells have been
detected in menstrual blood which are
specific for embryonic or adult stem cells
Angiogenesis plays a role in the
implantation and progression of
endometriosis similar to malignant
tumours.7

7. K.-W. Schweppe1, T. Rabe2 (DGGEF e.V.), M. Langhardt1, J.

Woziwodzki1, F. Petraglia3 (EEL), L. Kiesel4 (SEF) Endometriosis
 Concept of Tissue Trauma - Leyendeckers
working group (1998) have suggested that
dysrhythmia and disruptions of the basalis and
the inner layer of the myometrium may cause
tissue defects.8
Leads to the entrainment of endome-trial stem
cells from the basalis into the peritoneum, where
they differentiate into endometriosis.

8. Leyendecker G, Kunz G, Noe M, Herbertz M, Mall G. Endometriosis:

dysfunction and disease of the achimetra. Hum Reprod Update 1998;
 Signs and Symptoms
2025% of patients are asymptomatic

The severity of endometriosis symptoms

and the probability of its diagnosis
increase with age the incidence peaks in
women in their 40s

Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani

PG. Endometriosis and pelvic pain: relation to disease stage and
 Pain

Chronic pelvic pain accounts for 10% of

outpatient gynecologic visits
Focal pain or tenderness on pelvic
examination is associated with pelvic
disease in 97% of patients and with
endometriosis in 66% of patients.9

9. Ripps BA, Martin DC. Focal pelvic tenderness, pelvic pain and
dysmenorrhea in endometriosis. J Reprod Med 1991;36: 470-2.
 Pelvic pain due to endometriosis is usually
chronic (lasting 6 months) and is associated
with dysmenorrhea (in 50 to 90% of cases),
dyspareunia, deep pelvic pain, and lower
abdominal pain with or without back and loin
pain9
unpredictably and intermittently throughout the
menstrual cycle or it can be continuous, and it can
be dull, throbbing, or sharp, and exacerbated by
physical acitivity.

9. Ripps BA, Martin DC. Focal pelvic tenderness, pelvic pain and
dysmenorrhea in endometriosis. J Reprod Med 1991;36: 470-2.
 Endometriosis and Infertility

About 25 to 50% of infertile women have

endometriosis, and 30 to 50% of women
with endometriosis are infertile10
Infertile women are 6 to 8 times more likely
to have endometriosis than fertile women
Distorted pelvic anatomy, endocrine and
ovulatory abnormalities, altered peritoneal
function, and altered hormonal and cell-
mediated functions in the endometrium.

10. Verkauf BS. The incidence, symptoms, and signs of

endometriosis in fertile and infertile women. J Fla Med Assoc.
 Major pelvic adhesions or peritubal adhesions
that disturb the tubo-ovarian liaison and tube
patency can impair oocyte release from the
ovary, inhibit ovum pickup, or impede ovum
transport.11
May have endocrine and ovulatory disorders,
including luteinized unruptured follicle syndrome,
impaired folliculogenesis, luteal phase defect,
and premature or multiple luteinizing hormone
(LH) surges.11
11. Schenken RS, Asch RH, Williams RF, Hodgen GD. Etiology of
infertility in monkeys with endometriosis: luteinized unruptured
 Diagnostic and Staging

Definitive method to diagnose and stage

endometriosis and evaluate the
recurrence of disease after treatment is
visualization at surgery12
Laparoscopic surgery minimally
invasive
Laparoscopic endometriosis

12. Brosens I, Puttemans P, Campo R, Gordts S, Kinkel K. Diagnosis

of endometriosis: pelvic endoscopy and imaging techniques. Best
 Staging does not correlate with severity
of pain or predict the response to
therapies for pain or infertility.
Nonsurgical diagnostic: transvaginal usg,
MRI, doppler usg
Levels of CA-125 may be elevated in
endometriosis, but this test is not
recommended for diagnostic purposes
because of poor sensitivity and specificity
 A revised scoring system of the American
Society for Reproductive Medicine is used
to determine the disease stage (ranging
from I, indicating minimal disease, to IV,
indicating severe disease).13
Based on type, location, appearance dan
depth of invasion of lesions and the
extent of adhesions.13

13. Revised American Society for Reproductive Medicine

classification of endometriosis: 1996. Fertil Steril 1997;67:817- 21.
13. Revised American Society for Reproductive Medicine
classification of endo- metriosis: 1996. Fertil Steril 1997;67:817- 21.
 Treatment

Medical Therapy

Surgical Therapy

ESHRE Endometriosis Guideline

Development Group, Sept. 2013

1. Treatment of endometriosis-associated
pain

2. Treatment of endometriosis-associated
infertility
 Treatment of endometriosis-associated
pain
Empirical treatment of pain

1. Hormonal Therapies
Hormonal contraceptives
Progestagens and anti progestagens
GnRH agonist
Aromatase Inhibitor

2. Analgesics
NSAIDs
Surgery for treatment of endometriosis-associated pain

Laparotomy and laparoscopy

Consider both ablation and excision of

peritoneal endometriosis
Laparoscopic uterosacral nerve ablation
(LUNA) as an additional procedure to
conservative surgery to reduce endometriosis-
associated pain Not recommended
When performing surgery in women with
ovarian endometrioma, clinicians should
perform cystectomy instead of drainage and
coagulation, as cystectomy reduces
 Deep endometriosis - consider
performing surgical removal of deep
endometriosis
Consider hysterectomy with removal of
the ovaries and all visible endometriosis
lesions, in women who have completed
their family and failed to respond to more
conservative treatments
 Adhesion prevention after endometriosis
surgery

oxidised regenerated cellulose (Interceed),

polytetrafluoroethylene surgical membrane (Gore-Tex)

fibrin sheet

sodium hyaluronate and carboxymethylcellulose combination

(Seprafilm)
polyethylene oxide and carboxymethylcellulose gel (Oxiplex/AP)

steroids,

dextran,

icodextrin 4% (Adept)

hyaluronic acid products

polyethylene glycol hydrogel (SprayGel)

Preoperative and Postoperative hormonal therapies for treatment of
endometriosis- associated pain

Cochrane review that concluded that there was no

evidence of a benefit of preoperative medical therapy
Postoperative adjunctive hormonal therapy within 6
months after surgery can be prescribed with the aim of
improving the outcome of surgery for pain
Secondary prevention, which is defined as prevention of
the recurrence of pain symptoms or the recurrence of
disease in the long-term (more than 6 months after
surgery)
Based on the current evidence (Cochrane review), the
GDG concluded that there is no proven benefit of
postoperative hormonal therapy (within 6 months after
surgery)
Treatment of endometriosis-associated infertility

Suppression of ovarian function (by

means of danazol, GnRH analogues, OCP)
to improve fertility in minimal to mild
endometriosis is not effective and should
not be offered for this indication alone
In infertile women with endometriosis,
clinicians should not prescribe hormonal
treatment for suppression of ovarian
function to improve fertility
 In infertile women with AFS/ASRM stage
I/II endometriosis, clinicians should
perform operative laparoscopy (excision
or ablation of the endometriosis lesions)
including adhesiolysis, rather than
performing diagnostic laparoscopy only,
to increase ongoing pregnancy rates
ART assisted reproductive therapy

ADENOMYOSIS
 Introduction
Benign invasion of endometrium into the
myometrium, producing a diffusely enlarged
uterus which microscopically exhibits ectopic non-
neoplastic endometrial glands and stroma
surrounded by a hypertrophic and hyperplastic
myometrium.14
invasion of endometrium into the uterine muscle
tissue
dysmenorrhea, menometrorrhagia and chronic
pelvic pain
14. C. C. Bird, T. W. McElin, and P. Manalo-Estrella, The elusive
adenomyosis of the uterus-revisited, American Journal of Obstetrics
 Pathopyhsiology

The chronic disruption of the boundary between

the basal layer of the endometrium and the
myometrium, known as the junctional zone (JZ)
JZ has several distinctive properties, and the
disruption of this zone is thought to contribute to
the chronic pelvic pain associated with
adenomyosis, as well as infertility, abnormal
menstrual bleeding and the development of
endometriosis
 Adenomyosis grows and regress in an
estrogen dependent fashion due to presence
of estrogen receptors in adenomyotic tissue 15
Four theories proposed : 15

Direct invasion of the endometrium into the

myometrium.
Embryologic misplaced pleuripotent Mullerian
remnants.
Invagination of the basalis along the
intramyometrial lymphatic system
Misplaced from bone marrow stem cells.

15. Ferenczy A. Pathophysiology of adenomyosis. Hum Reprod

Update. 1998;4(4):312- 322.
 Adenomyosis and
Dysmenorrhea
Painful menstruation occurs in approximately 15-30% of
patients with adenomyosis.
This may be secondary to bleeding and swelling of areas
of endometrial tissue within the myometrium or it may
be secondary to the increased prostaglandin production
in adenomyotic tissue compared to normal myometrium.
Studies have shown that there is increased production of
prostaglandins within adenomyotic tissue compared to
normal myometrium a
There is significantly more prostaglandin and eicoisanoid
production in patients with severe dysmenorrhea
compared to patients who reported no dysmenorrhea
 Symptoms

Dysmenorrhea

Menometrorrhagia

Chronic pelvic pain

Dyspareunia

Tender uterus upon examination

Shrestha, A. and L. B. Sedai (2012). "Understanding clinical features

of adenomyosis: a case
 Diagnostic approach

Transvaginal ultrasound

Sonographical findings that can justify an

adenomyosis diagnosis are:
1. A globular uterine configuration
2. Poor definition of the endometrial-
myometrial interface
3. Subendometrial echogenic linear striation
4. Myometrial anterior-posterior asymmetry
5. Intramyometrial cysts
6. A heterogeneous myometrial echo texture
Exacoustos et al. (2011) Adenomyosis: three-dimensional
sonographic findings of the
 MRI
highly predictive of the presence of
adenomyosis includes a JZ measuring
>12mm and hemorrhagic high signal
myometrial spots
helpful when planning what type of
surgical treatment could be appropriate
high cost examination, the procedure
takes a lot of time
 Three objective parameters have been
identified for diagnosing adenomyosis on
MRI:
Thickening of the JZ 12mm
A ratio of maximum thickness of the JZ
(JZmax)/total maximum myometrial
thickness > 40%
A difference between JZmax and JZmin
(maximum thickness of JZ minimum
thickness of JZ = JZ difference) > 5mm.
 Treatment

Medical
Analgetic NSAIDs,
Oral Contraceptives
GnRH agonist
Levonorgestrel intrauterine system
Danazol
Aromatase inhibitors

Surgical
Endometrial ablation and resection
Excision of the myometrium
Hystercetomy

Garcia, L. and K. Isaacson (2011). "Adenomyosis: review of the

literature." J Minim Invasive Gynecol 18(4): 428-437.
 References
1. Linda C. Giudice, M.D., Ph.D., The New England Journal, Endometriosis, June 2010

2. Schweppe KW, Rabe T, Langhardt M, Woziwodzki J Petraglia F, Kiesel L J.

Reproduktionsmed, Endometriosis Pathogenesis, Diagnosis, and Therapeutic
Options for Clinical and Ambulatory Care. 2013; 10 (Sonderheft 1), 102-119

3. Terri Bloski, RN, BscN[Graduate Student] and Roger Pierson, MS, PhD, FEAS,
FCAHS[Professor and Director in Obstetrics, Gynecology and Reproductive Sciences]
University of Saskatchewan in Saskatoon, Saskatchewan, Canada, Endometriosis
and Chronic Pelvic Pain, Nurs Womens Health. 2008 October ; 12(5): 382395

4. Gabriella Zito,1 Stefania Luppi,2 Elena Giolo,2 Monica Martinelli,2 Irene Venturin,1
Giovanni Di Lorenzo,1 and Giuseppe Ricci, Medical Treatments for Endometriosis-
Associated Pelvic Pain, Hindawi Publishing Corporation BioMed Research
International, Volume 2014

5. Guideline of the European Society of Human Reproduction and Embryology, ESHRE

Endometriosis Guideline Development Group September 2013

6. Neil P. Johnson, and Lone Hummelshoj1, for the World Endometriosis Society
Montpellier Consortium, Consensus on current management of endometriosis,
University of Auckland, Auckland, New Zealand