Endometriosis and Adenomyosis

Bahaa Mali
Endometriosis is a common condition which is defined as
endometrial tissue lying outside the endometrial cavity.

It is usually within peritoneal cavity, predominantly

within the pelvis.

Commonly on the ovaries and uterosacral

ligaments.

It can also be found in other sites such as umbilicus,

abdominal scars, nasal passage and pleural cavity
• Incidence :

• Occurs in approximately 1–2% of women of

reproductive age.

It is the most common benign gynaecological

condition, estimated to be present in between
10 and 15 per cent of women.
• It is estrogen dependent condition so
its resolve after menopause or when
treatment directed towards inducing
pseudomenopause.
 Pathophysiology
• _ endometriotic tissue responds to cyclical
hormonal changes and therefore undergoes
cyclical bleeding and local inflammatory
reaction.
• _ repeated bleeding and healing leads to
fibrosis.
• _the cyclical damage cause adhesions between
associated organs causing pain and infertality
• When the ovaries are involved, they can
become enlarged with cystic, blood-filled
spaces that, on gross examination, are termed
chocolate cysts, or endometriomas.
Chocolate cyst
 Etiology

• The etiology of endometriosis is unknown ,

although there many theories:

1_ Menstrual regurgitation and implantation )

Sampson’s theory(
menstrual regurgitation of viable endometrial
glands and tissue within the menstrual fluid and
subsequent implantation on the peritoneal surface
2- Coelomic epithelium transformation
)Meyer’s theory(
The transformation of peritoneal mesothelial
cells to endometrial glandular cell.

3_Genetic and immunological factors

• Increased incidence in first-degree relatives
• Racial differences : increased incidence among
oriental women and a low prevalence in
women of Afro-Caribbean origin
 4 - Vascular and lymphatic spread

Vascular and lymphatic embolization to distant

sites has been demonstrated and explains the
rare findings of endometriosis in sites outside
the peritoneal cavity
 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.
• there is a lack of correlation between extent
of disease and the intensity of symptoms.
Symptoms may begin a few days before menses
starts until the end of menses.
Pelvic pain presenting with colicky pain throughout
the menstrual cycle may be associated with irritable
bowel syndrome symptoms.
Deep pain with intercourse(deep dyspareunia) can
also indicate the presence of endometriosis in the
pouch of Douglas.
Endometriosis in distant sites can cause local
symptoms, for example cyclical epistaxis with nasal
passage deposits, cyclical rectal bleeding with bowel
deposits , coughing up blood at the time of menses .
 Physical examination

Endometriosis can be suspected by clinical

findings on vaginal examination of thickening
or nodularity of the uterosacral ligaments,
tenderness in the pouch of Douglas, an
adnexal mass or a fixed retroverted uterus.
 Investigations

• Ultrasound :
-Transvaginal ultrasound can detect gross
endometriosis involving the ovaries
(endometriomas or chocolate cysts).
- In smaller lesions, ultrasound is of limited
value. However, the use of ultrasound can be
reassuring by excluding gross disease.
transvaginal ultrasound scan of an Endometrioma.
 Magnetic resonance imaging

• MRI can detect lesions >5 mm in size,

particularly in deep tissues, for example
rectovaginal septum. This can allow careful
pre-surgical planning in difficult cases
Laparoscopy
- it is the traditional method for diagnosis.
- It is based on the accuracy of the visual
diagnosis of endometriotic lesions, which
is dependent upon the experience of the
laparoscopist .
- The advantage of laparoscopy is that it
affords concurrent surgical diathermy
and/or excision of the endometriotic
lesions and also a staging of the disease.
The endometriosis lesions can be red, puckered, black ‘matchstick’ or white fibrous lesions .
 Endometriosis and infertility

 30-40 % of patients complain of subfertility .

 Multifactorial pathogenesis :
• Presence of a few small endometriotic deposits
• Anatomical distortion, with peri-adnexal
adhesions and destruction of ovarian tissue
when endometriomas develop
 Medical treatment of endometriosis does not
improve fertility and should not be given to
patients wishing to conceive.

 However, surgical ablation/excision of

minimal and mild endometriosis does improve
fertility chances.
Infertility and endometriosis – possible
mechanisms
 Management
• Challenging and difficult to treat .
• Endometriosis is known to be a recurrent
disorder throughout the whole of reproductive
life and it is impossible to guarantee complete
cure.
• Coexisting additional diseases such as irritable
bowel/ constipation (present in up to 80 per
cent of cases) should also be treated to
improve overall success rates
• Treatment should tailored for individual
according to her age ,symptom , extent of the
disease and her desire for future childbearing.
 Medical therapy

Analgesics

• Non-steroidal anti-inflammatory drugs

(NSAIDs), symptom control only.
Combined oral contraceptive agents
- Diagnostic and therapeutic purposes
- COC should be prescribed to be taken continuously for
an initial six month period, to render the patient
amenorrhoeic:
• If symptoms of cyclical pelvic pain disappear (in the absence of
any gross endometriosis on ultrasound, e.g. endometrioma),
the diagnosis is one of minimal/mild endometriosis.
• If symptoms persist then there is likely to be coexisting
irritable bowel disease/constipation which requires its own
treatment strategies of high fiber and adequate fluid intake.
• 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.
• Progestogens
• Used in those where there are risk factors for
the use of COC
• As long as amenorrhoea can be induced,
symptoms related to endometriosis should be
alleviated
• The use of levonorgestrel intrauterine
systems (LNG-IUS) has been shown to be
effective in achieving a long-term therapy
effect, particularly after surgical treatment
 Danazol/gestrinone

• The use of danazol and gestrinone, ovarian

suppressive agents, are now not commonly
used agents.
- Although effective, side effects, such as
androgen effects, for example weight gain,
greasy skin and acne hirsutism over long
• term (>six months), alterations in lipid profiles
or liver function, limit their use.
 Gonadotrophin-releasing hormone agonists

(GnRH-A) are as effective as danazol in relieving the

severity and symptoms of endometriosis and differ
only in their side effects. These drugs induce a state of
hypogonadotrophic hypogonadism or pseudo-
menopause with low circulating levels of oestrogen.
Side effects include symptoms seen at the
menopause, in particular hot flushes and night sweats.
• Despite these side effects, the drugs are well tolerated
and they have become established agents in the
treatment of endometriosis
Long-term use (>six months) can lead to drug-induced
osteoporosis, limiting its use. The administration of
low-dose hormone replacement therapy (HRT), along
with
• the GnRH-A analogues, the so-called ‘add-back’
therapy, may offer a way of preventing the adverse
effects of oestrogen deficiency.

 The recurrence of symptoms on cessation of therapy

is usually rapid, therefore the long-term use of GnRH
should be restricted to diagnostic purposes and where
it is used to suppress menstruation, in addition to
using longterm therapy, such as the LNG-IUS system
 Surgical treatment

• Conservative surgery :
Laparoscopic surgery with techniques such as diathermy,
laser vaporization or excision has become the standard for
the surgical management of endometriosis.

Endometriotic cysts should not just be drained but the inner

cyst lining should be excised or destroyed.

Recurrent risks following conservative surgery are as high as

30 per cent and therefore concurrent long-term medical
therapy is usually useful.
• Definitive surgery:
Where there are severe symptoms or progressive
disease or in women whose families are complete,
definitive surgery for the relief of dysmenorrhoea and
pain necessitates hysterectomy and bilateral
salpingooophorectomy, which is usually curative. The
removal of the ovaries is essential in achieving long-term
symptom relief.
The commencement of combined HRT may be deferred
for up to six months following surgery, particularly when
active disease was found to be present at the time of
laparotomy, to prevent activation of any residual disease
Adenomyosis
• Adenomyosis is a disorder in which
endometrial glands are found deep within the
myometrium

• Etiology:
• Adenomyosis is increasingly being viewed as a
separate pathological entity affecting a
different population of patients with an as yet
unknown and different etiology.
• Epidemiology
• Patients with adenomyosis are usually multiparous
• and diagnosed in their late thirties or early forties

• Presentation
• They present with increasingly severe secondary
• dysmenorrhoea and increased menstrual blood loss
(menorrhagia)

• Examination findings:
• Bulky and sometimes tender ‘boggy’ uterus,
particularly if examined perimenstrually
• Diagnosis
• Ultrasound examination of the uterus may be
helpful for diagnosis when adenomyosis is
particularly localized showing haemorrhage-
filled, distended endometrial glands.

• MRI is the more definitive investigation of

choice as it provides excellent images of the
myometrium, endometrium and areas of
adenomyosis
 Treatment

Given the practical difficulty in making the diagnosis

of adenomyosis preoperatively, conservative surgery
and medical treatments are so far poorly developed.
 In general, any treatment that induces
amenorrhoea will be helpful as it will relieve pain
and excessive bleeding. On ceasing treatment,
however, the symptoms rapidly return in the
majority of patients, and hysterectomy remains the
only definitive treatment