Endometriosis & Adenomyosis

Omar Al Omari, MRCOGObstetrician & GynaecologistJordan Hospital Medical Center*

*Endometriosis

*Definition: Abnormal growth of endometrial tissue outside the uterine cavity.

*Incidence and Prevalence:Increased significantlyRange from 1 50% General population:1 2% Infertile women:30 50%Occurs primarily in women in 25 45s

*Pathogenesis:Implantation Theory Retrograde Menustration Theory Sampson1921Lymphatic and Vascular Dissemination Theory Javert1952Coelomic Theory MeyerGenetic TheoryImmune System Dysfunctionimmunologic theory

*Genetic factorsFamilial clustering of endometriosis is a common clinical observation.In families with endometriosisthe disease is often confined to the maternal lineand is 7 times more common in first-degree relatives than in the general population.In future studiesevaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.

*Immunologic TheoryLose control of immunologic balanceBoth cellular immunity and humoral immunity change.Macrophage release IL1IL6TNFEGFFGF etc. stimulate TB lymphocyte proliferation and activationActivity of killer cellNK cell and T cell Produce antiendometrium antibodyAbnormal expression of CAMscell adhesion molecules

*The pathogenesis is unclear.

multifactorial

*Pathology macroscopic appearance1The commonest sitesOvarychocolate cystPeritoneum of the rectovaginal culdesac of the Pouch of DouglasUterosacral ligaments Sigmoid colonBroad ligament

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This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst.

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*Pathology macroscopic appearance 2Less common sitesCervixRound ligamentUrinary systembladderureterUmbilicusAppendixLaparotomy scars

*Multiple appearances of endometriosis implantsBrownishdiscolored peritoneumSuperficial peritoneal ecchymosisRaisedreddishsuperficial nodulesReddishblue invasive nodulesFibroticwhitish nodulesRaisedglossytranslucent blobsPatchywhite opacified peritoneumReddish or bluish ovarian cysts

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Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas. Such areas of endometriosis can be seen and obliterated by cauterization via laparoscopy.

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Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.

*Pathology microscopic appearanceHistomorphologically similar to eutopic endometrium

Four major components endometrial glands endometrial stroma fibrosis hemorrhage

*Clinical Manifestation

*SymptomsPain progressive dysmenorrhea dyspareunia painful defecationMenstrual disturbanceinfertility

*SignsEnlargement of the ovariesfixedFixed retroversion of the uterusTender nodules within the pelvis

Cannot be diagnosed by PV alone.Should always be considered when patients have symptoms referable to the pelvic cavity.

*Very variableVary with the focus locationOften bear no relation to the extent of the diseaseQuite often deposits are found incidentally in women who have no symptoms. 25% have no symptoms

*DiagnosisHistoryPV examinationLaparoscopygolden standardUltrasonographyBtype ultrasoundCA125 200U/mlnormal value 35U/mlAntiendometrium antibody+

*Staging systemsIn the AFS-r1985staging systempoints are assigned for severity of endometriosis based on the size and depth of the implant and for the severity of adhesions.The points are summed and the patients are assigned to one to four stagesStage I minimal disease 15 pointsStage II mild disease 615 pointsStage III moderate disease1640 pointsStage IV severe disease 40 points

*Differential diagnosisMalignant ovary tumours

Pelvic inflammatory masses

Adenomyosis

*Treatment

*Expectant therapyIndicationswith very limited disease

whose symptoms are minimal or nonexistent

If trying to get pregnantthe best way is to accept laparoscopic therapy as early as possible.

*Medical therapyIndicationschronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation

Hormoneinhibition therapy

*DrugsDanazolpseudomenopause therapyGestrinoneGnRH amedical oophorectomy add back therapyMifepristone RU486Progestogenspseudopregnancy therapy

*Surgical therapy1Indications1adnexal mass 2pelvic pain 3infertilityApproaches (1) trans abdominal (2) laparoscopic

*Surgical therapy2MethodsConservative surgerypreserve the fecunditypreserve the ovarian functionDefinitive surgery hysterectomy + salpingooophorectomy

*Combination medicalsurgical treatmentThreestep

surgerymedical therapysecond looklaparoscopy

* It is important to individualize the choice of therapy.

Therapy must be tailored to the degree of symptomatologythe patients ageher desire to maintain fertility

*Prognosis

With proper treatmentthe prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis.In most caseshormonal therapy is temporarily effective in controlling symptoms and arresting growth but is generally less effective than surgery in increasing fertility. The recurrent rate is very high.

*PreventionAvoid possible augmentation of menstrual reflux.

Taking oral contraceptive is recommended.

Isolation and irrigation of the operative site.

*Critical points1The pathogenesis is poorly understoodbut emerging evidence supports the causative role of retrograde menstruation and implantation of endometrial tissue.

Endometriosis is a common in women with pelvic pain or infertility.

Laparoscopy is the optimal technique to diagnose pelvic endometriosis.

*Critical points2In most casessurgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility.Alternativelymedical therapy with progestinsdanazolgestrinone or GnRH-a will ameliorate pelvic painbut they do not enhance fertility.Endometriosis is a recurrent diseaseand definitive treatment with removal of pelvic organs may be necessary.

*Adenomyosis

*Definition A benign uterine condition in which endometrial glands and stroma are found deep in the myometrium.

*EtiologyBasal endometrial hyperplasia invading a hyperplastic myometrial stroma.Four primary theoriesHeredityTraumaHyperestrogenemiaViral transmission

*Pathology gross appearanceUsually hyperemic with thickened wallsThe foci are frequently scattered diffusely throughout the myometrium.Occasionallymay be more circumscribedwith the formation of a distinct nodulean adenomyoma.

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The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis. There is also a small white leiomyoma at the lower left.

*Clinical features1Symptomatic adenomyosis occurs primarily in parous women over the age of 40 . 30 50Classic symptoms secondary dysmenorrhea abnormal uterine bleeding

*Clinical features2Most common physical sign a diffusely enlarged uterus (rarely exceeds 12 weeks gestation in size) particularly tender during menstruation

*DiagnosisHistoryPelvic examinationsUltrasonographySerum markersCA-125

*TreatmentHormone therapyHysterectomythe only uniformly successful treatment for adenomyosisis necessary.

Thank You*