ENDOMETRIOSIS AND

ADENOMYOSISLectures on Gynecology

Dr Magda Helmi

Introduction

Endometriosis is a common condition which is defined as endometrial tissue lying outside the endometrial cavity. It is usually found within the peritoneal cavity, predominantly within the pelvis, commonly on the uterosacral ligaments. It can also be found in other sites such as umbilicus, abdominal scars, nasal passages and pleural cavity.

Aetiology

Endometriosis occurs in approximately 1-2 per cent of women of reproductive age.

It is the most common benign gynaecological condition, estimated to be present in between 10 and I5 per cent of women.

It is a condition that is oestrogen dependent

theories that explains the etiology of endometriosis:Menstrual regurgitation and implantation

Coeiomic epithelium transformation

Meyer’s `coelomic metaplasia theory

Genetic and immunological factors

Vascular and lymphatic spread

Diagnoses

A laparoscopy or laparotomy procedure is used when trying to diagnose endometriosis.

Ultrasounds, MRIs, and CAT scans are not conclusive when diagnosing endometriosis.

Endometriosis can only be diagnosed through surgery.

Clinical features

Symptoms: Symptoms may begin a few days before menses starts until the end of menses.

Dysmenorrhea

Infertility

Painful sexual intercourse

Painful bowel movements

Fatigue

Heavy or irregular bleeding

Pain during ovulation

Gastrointestinal problems

Painful urination

Lower back pain

It is well recognized that there is a lack of correlation between extent of disease and the intensity of symptoms.

Chronic or intermittent pelvic pain

Classical clinical features are severe cyclical non colicky pelvic pain restricted to around the time of menstruation, sometimes associated with heavy menstrual loss.

sit symptoms

Female reproductive tract Dsymenorrhoea

Lower abdominal and pelvic pain

Dyspareunia

Rupture/torsion endometrioma

Low back pain

Infertility

Urinary tract Cyclical haematuria/dysuria

Ureteric obstruction

Gastrointestinal tract Dyschezia (pain on defecation)

Cyclical rectal bleeding

Obstruction

Surgical scars/umbilicus Cyclical pain and bleeding

Lung Cyclical haemoptysis

Haemopneurnothorax

Symptoms of endometriosis in relationship to site of lesion

Physical examination

It can be suspected by clinical findings on vaginal examination:Thickening or nodularity of the uterosacral ligaments, Tenderness in the pouch of Douglas, An adnexal mass or a fixed retroverted uterus.However, pelvic tenderness alone is nonspecific and differential diagnoses for restricted mobility of the uterus include chronic pelvic inflammatory disease and uterine, ovarian or cervical malignancy. In these conditions, other suggestive features are usually present.

Investigations

Ultrasound

Transvaginal ultrasound can detect gross endometriosis involving the ovaries (endometriomas or chocolate cyst).

In smaller lesions, US is of limited value.

However, the use of ultrasound can be reassuring by excluding gross disease.

Investigations

Magnetic resonance imaging

MRI is essential for an accurate differential diagnosis.

MRI can evaluate areas otherwise inaccessible by laparoscopy, identifying and evaluating the extent of lesions in the sub–peritoneal region and in the presence of dense adhesions.

MRI plays an essential role in the preoperative evaluation of patients with deep pelvic endometriosis.

Investigations

laparoscopy

The advantage of laparoscopy is that it affords concurrent excision of endrometriotic lesions and also a staging of the disease.

Stage Progression Tissue Description

I Minimal Presentation of 2-3 superficial implants.

II Mild Appearance of more implants that occur

Within deeper layers of tissue.

III Moderate Many deep implants in combination With minor/small endometriomas

on one or both ovaries. May also present filmy adhesions.

IV Severe Persistence of deep implants, enlargement of endometriomas on one or

both ovaries, development of dense adhesions.

Staging of the disease.

Ovarian function Luteolysis caused by prostaglandins F2

Oocyte maturation defects

Endocrinopathies

Luteinized unruptured follicle syndrome

Altered prolactin release

Anovulation

Tubal function Impaired fimbrial oocyte pick-up

Altered tubal motility

Coital function Deep dyspareunia - reduced

coital frequency

Sperm function Antibodies causing inactivation

Macrophage phagocytosis of spermatozoa

Early pregnancy failure Prostaglandin induced

Immune reaction

Luteal phase deficiency

Infertility and endometriosis possible mechanisms

Management

Patients with endometriosis are often difficult to treat, not only from a physical point of view, but also often because of associated psychological issues. Therapies designed for long-term strategies should be used.

Endometriosis is known to be a recurrent disorder throughout the whole of reproductive life and it is impossible to guarantee complete cure.

Medical therapyAnalgesicsNon-steroidal anti-inflammatory drugs (NSAIDs) are potent analgesics and are helpful in reducing the severity of dysmenorrhoea and pelvic pain. However, they have no specific impact on the disease Hormonal Drug Therapy:Hormonal drugs are given to try to stop ovulation for as long as possible in order to keep the implants or lesions from beingaggravated. Most of these therapies can only be given for a limited amount of time, and the side effects can cause problems for some women. Hormonal drug therapy is used to ward off symptoms and is often most effective when used after surgical treatment has been done.Combined oral contraceptive agentsOral contraceptive agents can be used for diagnostic and therapeutic purposes. COC should be prescribed to be taken continuously for an initial six- month period, 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.ProgestogensIn those where there are risk factors for the use of OCC.Danazol/gestrinoneThe 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 over long term (>six months), alterations inlipid profiles or liver function, limit their use. GnRH agonists.Gonadotrophin-releasing hormone agonists 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 effect. These drugs induce a state of pseudo-menopause.

Surgical TreatmentLaparoscopic Surgery Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis.Hysterectomy

Adenomyosis

The term adenomyosis is derived from the Greek terms adeno- (meaning gland),myo-(meaning muscle), and -osis (meaning condition). Previously named as endometriosis interna, adenomyosis actually differs from endometriosis and these two disease entities are found together in only 10% of the cases.

The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrheal & menorrhagia, respectively). However, because the endometrial glands can be trapped in the myometrium, it is possible to have increased pain without increased blood. (This can be used to distinguish adenomyosis from endometrial hyperplasia; in the latter condition, increased bleeding is more common.)In adenomyosis, basal endometrium penetrates into hyperplastic myometrial fibers. Therefore, unlike functional layer, basal layer does not undergo typical cyclic changes with menstrual cycle.Adenomyosis may involve the uterus focally, creating an adenomyoma. With diffuse involvement, the uterus becomes bulky and heavier.

The cause of adenomyosis is unknown, although it

has been associated with any sort of uterine trauma, such as a caesarean section, tubal ligation, pregnancy termination, and any pregnancy. It can be linked with endometriosis, but studies looking into similarities and differences between these two conditions have conflicting results.The differential of abnormal uterine bleeding includes• endometrial polyps• submucus fibroids• endometrial hyperplasia• endometrial carcinoma

Signs and symptoms

Some women with adenomyosis do not experience any symptoms, while others may have severe, debilitating symptoms. Intense debilitating pain all the time and/or

•Acute & increasing pain at menstruation and ovulation

•Strong 'contraction' feel of uterus

•Abdominal cramps

•A 'bearing' down feeling

•Pressure on bladder

•Dragging sensation down thighs and legs

•Heavy bleeding and flooding

•Large blood clots

•Prolonged bleeding i.e.; up to 8–14 days

hysrotoscopy

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MRI). A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal).Conservative treatment often consists of anti-inflammatory medications. Hormonal manipulation. Hormonal suppression Hysterectomy may be warranted in some cases,