15/01/2024

Endometriosis and adenomyosis

M. Khaled Hamwi - 1129200919502

Sri Amelia Natasha - 1129200919455
Nurul Farhanim - 1129200919568
Tuan Nur Syahirah Amani – 1129200919460
Muhammad Syamil - 1129200919453

Supervised By: Prof. Dr. Che Anuar Che Yaakob

 Endometriosis
Endometriosis is a common condition that is defined as endometrial tissue lying outside
the uterine cavity.
• It is usually found within the pelvis, commonly located:
 On the peritoneum lining the pelvic side wall
 Pouch of Douglas
 Uterosacral ligaments
 Bladder

 This ‘ectopic’ endometrial-like tissue can induce fibrosis and be found infiltrating into
deeper tissue such as the rectovaginal septum and bladder.
 When endometrial tissue is implanted into the ovary, an endometrioma forms.
 This cyst may be large and contains old, altered blood that has a thick brown appearance,
and for this reason is frequently referred to as a ‘chocolate cyst’.
 Less commonly, endometriotic deposits can be found in other sites such as umbilicus,
abdominal scars and the pleural cavity.
• Endometriotic tissue responds to cyclical hormonal changes and therefore
undergoes cyclical bleeding and local inflammatory reactions.
• These regularly repeated episodes of bleeding and healing lead to fibrosis
and adhesion formation between pelvic organs, causing pain and infertility.
• In extreme cases a ‘frozen pelvis’ results, where extensive adhesions tether the
pelvic organs and obliterate normal pelvic anatomy.

Epidemiology
• Endometriosis occurs in approximately 5–10% of women of reproductive age. It is found
in at least one-third of women undergoing a diagnostic laparoscopy for pelvic pain or
infertility.
• It is a condition that is oestrogen dependent and therefore it resolves after the
menopause or when treatment is directed towards inducing a pseudomenopause.
• Endometriosis affects roughly 10% (190 million) of reproductive age women and girls
globally (WHO & RCOG, 2023)
Obstetrical & Gynaecological Society of Malaysia, 2019
Adenomyosis
• Adenomyosis is a uterine condition often seen with endometriosis, where
islands of endometrial tissue are found deep within the underlying
myometrium.
• The endometrium is usually well demarcated from the underlying myometrium.
Adenomyosis is a disorder in which endometrial glands and stroma are found
deep within the myometrium.
• Adenomyosis is the existence of ectopic endometrial glands and stroma within
the myometrium with myometrial hypertrophy and hyperplasia (Malaysia Journal
of Public Health Medicine)
• This ectopic endometrium is responsive to cyclical hormonal changes that result
in bleeding within the myometrium, leading to increasingly severe
secondary dysmenorrhoea, uterine enlargement and heavy menstrual bleeding.
Epidemiology of
Adenomyosis
• Women with adenomyosis are usually
multiparous and diagnosed in their late
30s or early 40s.
• Prevalence of adenomyosis at the time of
hysterectomy has been estimated
anywhere between 14% and 66%.
• A mean frequency of 20-30% has been
reported and has been extrapolated to
suggest the same incidence in the general
population.
• Risk factors include increased parity,
spontaneous abortions, uterine surgery,
and middle age.
Pathophysiology (Theory of
Endometriosis and
Adenomyosis)
Sampson's Theory
(Retrograde Menstruation)
• The main idea of it is that menstrual blood
containing endometrial cells regurgitate via patent
fallopian tubes into the peritoneal cavity, where
the implantation of these cells might occur After implantation,
development and
growth of the lesion is
• It explains ovarian and superficial peritoneal supported by
angiogenesis
endometriosis, but not deep infiltrating
endometriosis or lesions outside the peritoneal
cavity
It is possible because
of activated peritoneal
macrophages, which
produce angiogenic
factors
Coelomic metaplasia
(Iwanoff-Meyer theory)
• Cells of original coelomic
epithelium can undergo
metaplastic change into Lymphatic or vascular dissemination
endometrial tissue • Endometrial tissue could circulate through
• This theory can explain blood vessels or the lymphatic system to
endometriosis in pleura other parts of the body
and peritoneal cavity • This may explain how endometriosis can
develop in distant sites from the pelvic
cavity, such as the lung
• This explanation alone fails to clarify how
the adhesion necessary to form the
endometriotic implant occurs at these
distant locations.
The embryonic remnant theory
• This theory proposes that residual
Müllerian cells, possibly upon
estrogen stimulation at puberty,
could be the origin of
endometriosis.
• However, the incidence of
endometriosis is higher after
the age of 25.
Immunological theory
• Decreased cellular immunity
to endometriotic tissue
• reduced clearance
from peritoneal cavity
• altered function of macrophages
Genetic predisposition and
environmental factors
• studies show that first-degree
relatives of people who have
had endometriosis are more likely
to develop the pathology
• 7-fold increase in incidence in
relatives of women with
endometriosis
• Epigenetic changes may
predispose to the development
of endometriosis.
Theories on the mechanisms of adenomyosis.
Theories on the mechanisms of adenomyosis.
(1) Invasion of endometrial basalis into
the myometrium
• Result from altered endometrial
basalis cells or cell groups invading
into the myometrium
• crossing an injured or abnormal
junctional zone
• subsequently establishing ectopic
adenomyotic lesions and inducing
hypotrophy and dysfunction of
myocytes
(2) Microtrauma of junctional zone
induced by TIAR
• The disarray of myocyte distribution
and irregularities of the nuclear
membrane in the IM in the setting of
adenomyosis suggest a contributory
role of disruption of this compartment
to the development of the disease
(3) De novo metaplasia from stem
cells
• Alternative hypotheses propose
that ectopic endometrium derives
by metaplasia de novo of
embryonic epithelial progenitors
(remnants) or differentiation of
adult endometrial stem cells that
transit to the myometrium
(4) Outside to inside invasion
induced by the retrograde
menstruation
• Adult endometrial cells (or stem
cells) in retrograde menstrual
effluent have the potential to
infiltrate the uterine serosa
and penetrate into the OM and
develop
into intramyometrial endometrial
implants
 Sign & Symptoms
Complications

Presented By: M. Khaled Hamwi - 1129200919502

 Learning objectives
Learners will be able to:
1. Know the classical clinical findings of endometriosis and adenomyosis
2. Understand the different locations of endometriosis and its associated
symptoms.
3. Know the physical examination findings of endometriosis and adenomyosis
4. Know the different complications of endometriosis and adenomyosis
CLINICAL FEATURES OF ENDOMETRIOSIS
• Patient Profile: The age is between 25 and 45 years old. The patients are
mostly nulliparous or have had one or two children, long years prior to
appearance of symptoms. Infertility, and higher social status are often
related. There is often family history of endometriosis.
It’s is found in at least one-third of women undergoing a diagnostic laparoscopy
for pelvic pain or infertility.
• About 25% of patients with endometriosis have no symptom, being
accidentally discovered either during laparoscopy or laparotomy
• Depth of penetration is more related to symptoms rather than the spread.
Lesions penetrating more than 5 mm are responsible for pain, dysmenorrhea,
and Dyspareunia
• The symptoms are mostly related to the site of lesion and its ability to
respond to hormones. Midline lesions are more symptom producing.
Symptoms of endometriosis: very variable, but “cyclic”
(e.g., exacerbated during menses) & non colicky pelvic pain

Causes of pain in endometriosis: Peritoneal inflammation (PGF,

cytokines) Tissue necrosis, Adhesion formation, Nerve irritation
due to deep penetration, Release of local inflammatory mediators,
Endometrioma formation
Comparison of the symptoms and
localisation of endometriosis
involvement according to fertility
status of endometriosis patients:
Journal of Obstetrics and
Gynaecology: Vol 38, No 4. Journal
of Obstetrics and Gynaecology.
Published 2018. ‌
• The classic symptom of endometriosis is pain, deep dyspareunia, secondary
dysmenorrhea infertility or pelvic pain. 'Crescendo' dysmenorrhoea is typical, where
the pain precedes the onset of menstruation by several days, reaches a climax, and is
relieved when bleeding commences.
• How does a women with adenomyosis present?
• i) Women are usually parous with age usually ≥40 years, multiparous ii) Menorrhagia
(70%) iii) Dysmenorrhea (30%) iv) Women in reproductive age suffer from infertility.
• Severe dysmenorrhea and menorrhagia are the most common symptoms of women
diagnosed with adenomyosis. Other common symptoms include intermenstrual spotting
and dyspareunia.
• Abnormal uterine bleeding: PALM (structural, rule out first) COEIN (non-structural):
Polyp (2.5%), Adenomyosis (8.5%), Leiomyoma (25.7%) , Malignancy and hyperplasia
(8.1%), coagulopathy (0.3%), Ovulatory dysfunction (28.2%), Endometrial causes
(14.5%), Iatrogenic (2.2%) Not yet classified (9.7%)
Vasava VH, Airao BB, Shingala MR. Palm-coein classification of abnormal uterine bleeding and clinic histopathological
correlation. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2021;10(4):1587-1591
• Physical examination of endometriosis:
• 1. Uterosacral nodularity: best appreciated on rectovaginal (bimanual) exam.
The uterosacral ligaments may feel scarred, nodular and irregular
• 2. Tenderness and/or nodularity in pouch of douglas
• 3. Fixed uterus or adherent pelvic structures; may have retroverted uterus due to adhesions
• 4. Adnexal mass may be palpable if endometrioma present

Physical examination of adenomyosis: i) Mass may be felt in the hypogastrium

ii) On pelvic examination—uterus is found uniformly enlarged and often it is often tender.
Not typically cause uterine enlargement beyond 12-14 weeks. The findings, however, may be
altered due to associated fibroid or pelvic endometriosis.

Endometriosis cannot be diagnosed by physical examination alone. However, enlargement of

the ovaries, fixed retroversion of the uterus, and tender nodules within the pelvis may each
raise the suspicion of the disease. Endometriosis should always be considered when patients
have symptoms referable to the pelvic cavity.
• How does pelvic endometriosis appear?
They appear as small black dots on
uterosacral ligaments and pouch of
Douglas. These also appear as ‘Powder
Burns’. Other appearances are: Red flame
shaped areas and yellow-brown patches.
Endometrioma (pseudocyst) often called
“chocolate cyst” because of appearance of
contents (i.e., old blood)
• COMPLICATIONS OF ENDOMETRIOSIS
• Endocrinopathy—responsible for infertility
• Rupture of chocolate cyst.
• Infection of chocolate cyst.
• Obstructive features: – Intestinal obstruction
– Ureteral obstruction (hydroureter, hydronephrosis) – renal infection.
• Malignancy is rare, the most common one is adenoacanthoma (more well
differentiated (benign looking) then adenosquamous ).
• COMPLICATIONS OF ADENOMYOSIS:
• Chronic anemia: due to menorrhagia
• Abnormal uterine bleed
• Miscarriage Women with adenomyosis have a higher incidence of infertility & miscarriage.
• Infertility (10-12%) (a) abnormal function of sub endometrium & myometrium.
(b) retrograde myometrial contractions.
(c) interference in sperm transport and blastocyst implantation.
(d) abnormal endometrial immune response and nitric oxide level.
References:
1. Vasava VH, Airao BB, Shingala MR. Palm-coein classification of
abnormal uterine bleeding and clinic histopathological
correlation. International Journal of Reproduction, Contraception,
Obstetrics and Gynecology. 2021;10(4):1587-1591
2. Comparison of the symptoms and localisation of endometriosis
involvement according to fertility status of endometriosis patients:
Journal of Obstetrics and Gynaecology: Vol 38, No 4. Journal of
Obstetrics and Gynaecology. Published 2018. ‌
3. Smolarz B, Krzysztof Szyłło, Romanowicz H. Endometriosis:
Epidemiology, Classification, Pathogenesis, Treatment and Genetics
(Review of Literature). International Journal of Molecular
Sciences. 2021;22(19):10554-10554.
 Investigation and Differential
diagnosis of Endometriosis and
Adenomyosis
TUAN NUR SYAHIRAH AMANI
1129200919460
Investigation (Endometriosis)
1. USG
• to investigate suspected endometriosis even if the pelvic
and/or abdominal examination is normal
• to identify endometriomas and deep endometriosis
involving the bowel, bladder or ureter.
1. Transabdominal USG
- Limited use evaluating endometriosis, especially
limited in detecting ovarian endometriomas
- Can reveal deep endometriosis with similar
efficacy as MRI Deep infiltrating endometriosis
2. Transvaginal USG (DIE) nodule of bladder appearing
- Not able to reliably exclude superficial disease as a protrusive nodule arising from
- Has sensitivity >over 90% in detecting deep the bladder base towards the lumen
endometriosis of bladder
2. Serum CA 125
• Do not use serum CA125 to
diagnose endometriosis.
• If a coincidentally reported serum
CA125 level is available, be aware
that:
 a raised serum CA125 (that is,
35 IU/ml or more) may be
consistent with having
endometriosis
 endometriosis may be present
despite a normal serum CA125
(less than 35 IU/ml).
3. MRI
• Do not use pelvic MRI as the primary investigation to diagnose
endometriosis in women with symptoms or signs suggestive of
endometriosis.
• Consider pelvic MRI to assess the extent of deep endometriosis involving
the bowel, bladder or ureter.
• Ensure that pelvic MRI scans are interpreted by a healthcare professional
with specialist expertise in gynecological imaging.
4. Diagnostic Laparoscopy
• Consider laparoscopy to diagnose endometriosis in women with suspected
endometriosis, even if the ultrasound was normal.
• For women with suspected deep endometriosis involving the bowel, bladder or
ureter, consider a pelvic ultrasound or MRI before an operative laparoscopy.
• During a diagnostic laparoscopy, a gynaecologist with training and skills in
laparoscopic surgery for endometriosis should perform a systematic inspection of
the pelvis.
• During a diagnostic laparoscopy, consider taking a biopsy of suspected
endometriosis:
o to confirm the diagnosis of endometriosis (be aware that a negative histological result does
not exclude endometriosis)
o to exclude malignancy if an endometrioma is treated but not excised.
• If a full, systematic laparoscopy is performed and is normal, explain to the
woman that she does not have endometriosis, and offer alternative management.
Differential
Diagnosis
(endometriosis)
Investigation (Adenomyosis)
1.Transvaginal sonography (1st 2. MRI (gold standard imaging for
line investigation) assessing JZ in evaluation of
•Offer transvaginal ultrasound adenomyosis)
-Significant dysmenorrhea (period pain) Characteristics;
-A bulky, tender uterus on examination T2-W: uterine enlargement characterized
that suggest adenomyosis by ill defined, hypointense within the
JZ means smooth muscle hyperplasia
Transabdominal Transvaginal (JZ thicker > 12 mm is generally
USG USG
accepted as diagnostic)
Sensitivity 32-36% 89% Disadvantage: expensive and not
available in every unit
Specificity 95-97% 89%

Jin-Jiao Li, Jacqueline P. W. Chung, Sha Wang, Tin-Chiu Li, Hua Duan, "The Investigation and
Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility", BioMed Research
International, vol. 2018, Article ID 6832685, 12 pages, 2018. https://doi.org/10.1155/2018/6832685
3. Hysterography

Figure 1. Irregular Figure 2.

endometrium with Hypervascularisation
Figure 3. An endometrial
openings.
“strawberry” pattern.
Differential diagnosis (Adenomyosis)
The signs and symptoms of adenomyosis are similar to other disease entities characterized by
abnormal uterine bleeding, dysmenorrhea, or infertility. The (FIGO) classification scheme utilizes
the PALM-COEIN mnemonic as a clinical tool for more consistent reporting practices.
o Polyps
• Adenomyosis often co-exists with other
o Adenomyosis entities within the differential diagnosis,
o Leiomyoma most commonly leiomyoma (50%),
o Malignancy/hyperplasia endometriosis (11%), and endometrial
polyps (7%).
o Coagulopathy
o Ovulatory dysfunction
o Endometrial
o Iatrogenic
o Not yet classified
MANAGEMENT
By: MUHAMMAD SYAMIL BIN
SANIGAPOR
 Based on Ten Teachers 20th Edition (2017)
o The treatment can be divided into medical and
surgical treatment
o Medical treatment can only be done if the
MANAGEME clinical examination and TVUSS are normal.
NT OF However if no symptoms relieved within 3 to 6
months, surgical intervention should be
ENDOMETRI considered
OSIS o Treatment should be tailored based on the
individuals ( age, symptoms, extent of disease
and desire to have children)
o Endometriosis is known to recur and
impossible to guarantee a complete cure.
MEDICAL THERAPY
Analgesics
• NSAIDS helps as a symptom control reducing the severity of the
symptoms(dysmenorrhea, pelvic pain). No impact on the disease.
• Avoid opiates as irritable bowel symptoms(80% of case) can worsen the pelvic pain
Combined Oral contraceptives (COCP)
• Can be considered in absence of contraindication such as desire for pregnancy.
• Helps in reducing endometriosis-related dyspareunia, dysmenorrhea and non
menstrual pain
• If COCP achieves symptomatic relief, can be continued for several years until there
is desire for pregnancy. If not, review coexisting condition(IBD) or alternative surgical
or medical should be done.
Progestogens
• Have risk factors for COCP? Use progestogens only to induce amenorrhea
o Eg: LARCs(depot-medroxyprogesterone) or LNG-IUS (Mirena)
o Both useful in giving long term therapeutic effect particularly after surgical
treatment. Effect 100% based on compliance.
Gonadotrophin-Releasing Hormone Agonists
• GnRH are effective in relieving the severity and symptoms of
endometriosis
• Despite side effects, still tolerated by some and used as treatment
• Administered as slow depot formulations for a month, not more than 6
months as it can cause drug induced osteoporosis
Other Hormonal Agents
• Ovarian suppresive agents(danazol and gestrinone)- used for good effect
but no longer appropriate. They have adrogenic side effects such as
weight gain and greasy skin.
• Newer class of drug called aromatase inhibitiors that inhibit the action of
enzyme aromatase,which convert androgens into estogrens and
expressed in endometriotic tissue. Further research still on going for their
use.
SURGICAL TREATMENT
Fertility-sparing Surgery
• It is done through laparascopically. The surgeon
can precisely remove endometriosis tissue through
small incisions in the abdomen without affecting or
minimizing the damage to the uterus and ovaries
and keeping the women fertility.
• Recurrent risk following conservative surgery are as high as 30% and therefore long term
medical therapy is often necessary and started right after surgery
Hysterectomy and Oopherectomy
• Removal of uterus and ovaries only to be considered in women who have completed their
families and failed to respond to more conservative treatments.
• Women should be informed that it is not necessarily cure the symptoms of disease.
• Estrogen only hormone replacement therapy(HRT) need to be started after surgery once
patient is mobile but some surgeons delay the use of HRT for up to 6 months to prevent
activation of any residual disease.
• Combined HRT can be considered as suppresive treatment where reactivation of new or
residual disease is suspected.
Based on the Endometriosis Guideline by the
European Society of Human Reproduction and
Embryology(2022):-
The medical and surgical treatment are still the
same as stated in Ten Teachers.
MANAGEMENT OF ADENOMYOSIS
Based on Ten teachers 20th edition (2017),
- Due to the difficulty to diagnose adenomyosis preoperatively, the surgical
and medical treatment are poorly developed.
- In general, any treatment that can cause amenorrhea will be helpful as it
will relieve the pain, excessive bleeding.
- Use of progestin containing LARCs such as LNG IUGS, depot Provero
and short term GnRH should be considered.
- Symptoms rapidly return in majority of patients
- Hysterectomy is the only definitive treatment