Endometriosis and

adenomyosis

• Janice Navarro, M.D

 Endometriosis
• Benign

• Presence and growth of glands and stroma

of the lining of the uterus in an aberrant or
heterotropic location

• Prevalence is 33% in women with chronic

pelvic pain

• 30-45% in women with infertility

 Causes
• Uncertain

• Retrograde menstruation

• Vascular dessimination

• Metaplasia

• Genetic disposition
• Typical patient in her mid 30's is
nulliparous, and involuntarily infertile

• Has symptoms of secondary dysmenorrhea

and pelvic pain

• The classic symptom is pelvic pain

 Retrograde
menstruation
• Secondary to implantation of endometrial
cells shed during menstruation

• These cells attach to the pelvic peritoneum

and under hormonal influence grow as
homologous grafts

• Found in women with outflow obstruction

of the genital tract
 Metaplasia
• Metaplasia of coelomic epithelium or
proliferation of embryonic rests

• Metaplasia occurs after an induction

phenomenon has stimulated the multipotential
cells

• The induction substance may be a combination

of menstrual debris and the influence of
estrogen and progesterone

• Invaginates into the ovarian cortex is the

pathogenesis of development of ovarian
endometriosis
 Lymphatic channels and
vascular metastasis

• Transplanted

• Helps explain rare endometriosis

 Iatrogenic
dissemination

• After cs

• Episiotomy
 Immunologic
changes
• More peritoneal macrophages that are
larger

• These cells secrete multiple growth factors

and cytokines that enhance the
development of endometriosis
 Genetic
predisposition

• First degree relatives 7%

 Pathology
• Located in the d pendent portions of the female pelvis

• Ovaries are most common site-bilateral

• Pelvic peritoneum over the uterus, anterior and posteriorcul de sac and
uterosacral, round and broad ligament

• Pelvic lymph node in 30%

• Cervix, vagina, and vulva, rectosigmoid

• They are red, brown, black white and yellow, pink clear or red vesicle

• The predominant color depends on the blood supply and the amount of
hemorrhage and fibrosis

• Size is also related to the size of lesion, degree of edema and amount of
inspissated material
• New lesions are small, bleblike implants
that are less than 1cm in diameter

• Powder burn and chocolate cysts

• Older are white with scarring

• Three cardinal histologic features are:

ectopic endometrial glands, ectopic
endometrial stroma and hemorrhages into
adjacent tissues
 Clinical findings
• Fixed, retroverted uterus with scarring and tenderness posterior
to the uterus

• Nodularity of the uterosacral ligaments and cul de sac may be

palpated in the rectovaginal examination

• Advanced cases: extensive scarring, and narrowing of the

posterior vaginal fornix.

• Ovaries may be enlarged and tender and are often fixed to the
broad ligament or lateral pelvic sidewalls

• Speculum exam : small areas of endometriosis on the cervix or

upper vaginA

• Lateral displacement or deviation of the cervix is visualized or

palpated
• Diagnosis confirmed with direct laparoscopic
visualization

• Biopsy selected implants confirms the dx

• Ultrasound examination

• MRI- not practical

• Diff dx: chronic PID, ovarian malignancy, degeneration of

myoma, hemorrhage, torsion of the ovarian cyst,
edenomyosis, primary dysmenorrhea, functional bowel
disease

• Occ large endometrioma may rupture, diff dx: ectopic

preg, appendicitis, diverticulitis, bleeding corpus luteum
• Endometriosis maybe associated with
ovarian cancer

• Increased risk of developing cancer

fourfold
 Management
• Two primary short term goals: relief of pain and
promotion of fertility

• The primary long term goal is attempting to

prevent progression or recurrence of the disease
process

• Choice of tx depends on age, future reproductive

plans, location, extent of disease, severity of sx,
and ass pelvic pathology

• Gold standard in Dx: laparoscopy

• Tx:medical, surgical or combination of both

• Conservative surgery: resection or
destruction of endometrial implants, lysis
of adhesion and attempts to restore
normal pelvic anatomy

• Definitive surgery: removal of both ovaries,

uterus, and all visible ectopic foci of
endometriosis
 Medical therapy

• Aimed at suppression of lesions and

associated symptoms particularly pain

• Achieved by menstrual suppression ideally

without inducing hypoestrogenism
 Danazol
• attenuated androgen that is active when given orally

• Produces hypoestrognic and hyperandrogeni. Effect

effect

• Induces atropic changes in the endometrium of the

uterus and similar changes in endometrial implants

• Total dose 200 mg od days 1-5

• S/e deepening of voice, mild elevation of liver

enzyme, decreased hdl, increased ldl

• 6-9 mths
 Gonadotropin releasing
hormones agonist
• Leuprolide3.75mg im once per mth or an
11.25mg every three months

• Goserelin acetate is given in a dosage of

3.6mg every 28 days in a biodegradable
subcutaneous implant

• S/e associated with decreased estrogen,

hot flushes, vaginal dryness, insomia
 Oral contraceptives
• Most economical regimen

• 6-12 months

• Aimed at complete suppression with

advantage over cyclic use

• Only concern is breakthrough bleeding

• S/e wt gain and breast tenderness

 NSAIDs

• Beneficial for pain relief and concomitant

therapy may improve the bleeding comtrol
of patients
 Others
• Provera 20-30mg orally per day

• DMPA 150 mg IM every three mths

• Dienogest -causes anovulation, has

antiproliferative effect on endometrial cells

• Levonorgestrel IUS
 Adenomyosis
• 35-50 yo

• Ectopic endometrial glands and stroma

• Asymptomatic, menorrhagia dysmenorrhe, dyspareunia

• Associated with increase parity, uterine surgeries and trauma, disruption

between endometrium and myometrium

• Posterior wall is usually involved

• Cut section: darker, dark cystic spaces

• Histo: benign endometrial glands and stromata are within the

myometrium more than one low powered field (2.5mm) from the basalis
layer of the ebdometrium

• Hyperplasia and hypertrophy of the myometrium

 Adenomyosis
• Enlarged diffusely >14 weeks aog

• Globular, tender immediately before and during

menstruation

• diagnosis confirmed with histo biopsy

• TVS,MRI- differentiates myoma from adenomyosis

• Mgt: GnRH agonist, progestigens, IUD Progesterone

containing, cyclic hormones,

• Hysterectomy- definitive treatment