Endometriosis &

Adenomyosis

dr. Selly Septina, SpOG

 Description of
Endometriosis
 presence of endometrial tissue, composed of
glands and stroma, at sites outside
endometrial cavity
 most common sites
– ovary
– broad ligament
– cul-de-sac
– rectovaginal septum
 endometrial tissue responds cyclically to estrogen
– swelling
– producing local inflammation
 severity of pain unrelated to extent of disease
– There may be more pain associated with active lesions
in mild disease than with adhesions in severe disease
 commonly occurs in women in 20’s and 30’s
– tends not to occur before menarche or after menopause
 major cause of infertility
 Theories for Etiology
 Sampson’s theory of retrograde
menstruation
 Halban’s lymphatic spread theory
 Meyer’s mullerian metaplasia theory
– metaplasia of mesothelial cells into endometrial
epithelium under some unidentified influence,
such as repeated inflammation
 Hematogenous spread
 Epidemiology
 found equally among all races
 more likely to occur and progress in
women with
– early menarche
– in those with menstrual flow exceeding seven
days
– cycles of less than 27 days
– years of menstruation uninterrupted by
pregnancy
– family history of endometriosis
 Incidence

 10-15 % of women of reproductive age

 40-50 % of women undergoing surgery for
evaluation of infertility
 average age at diagnosis is 28
 History
 most common symptoms
– dysmenorrhea
– dyspareunia (especially on deep penetration)
– perimenstrual back pain
– infertility
 other symptoms reported
– dyschezia
– abdominal pain
– irregular bleeding patterns, especially pre-
menstrual spotting
 less common symptoms
– urgency in urination
– hematuria
– rectal bleeding
 Physical Exam Findings
 may appear normal if lesions = small & few
 advanced disease
– cervical displacement of 1 cm or more to the
left or right of midline
– bimanual exam tenderness and nodularity of
the uterosacral ligaments and posterior cul-de-
sac are detected
– adnexal masses that vary in size, shape, and
consistency and may be asymmetric, fixed,
cystic, or indurated
– fixed retroversion of the uterus
 Endometriosis on /in the
Ovary
 Forms a dark, chocolate cystic mass.
 Diagnostic Tests
 CA-125 elevated
 CBC normal
 Diagnostic laparoscopy

http://medstat.med.utah.edu/kw/human_repro
d/mml/hr08.html
 Differential Diagnoses
 chronic PID
 recurrent acute salpingitis
 hemorrhagic corpus luteum
 benign or malignant ovarian neoplasm
 ectopic pregnancy
 adenomyosis
 Treatment Plan
 psychosocial intervention
 medications
– danazol
– progestogens
– combined Ocs
– gonadotropin-releasing hormone agonists
(GnRH-a)
• Lupron injection qmo x 6 mos
• Synarel nasal spray bid x 6 mos
 surgical interventions: conservative vs.
definitive
 GnRH analogs
 Decreases secretion of gonadotropins
 Major concerns are…
– Cost
– Parenteral administration
– Potential for accelerated bone mineral loss
– Hot flashes & hypo-estrogen states
 Adenomyosis
 Growth of the glands & stroma within the
myometrium (muscle wall)
 Affects the parous women over 40 y/o
 Etiology - downward growth of surface
endometrium
 Adenomyosis - S &S
 Dysmenorrhea
 Menorrhagia
 Bulky, boggy, tender, uterus on exam : if
menstruating, uterus may be board-like!
 Treatment of Adenomyosis
 Medical therapy used to treat endometriosis
does not help!
 Abdominal Hysterectomy
 Will cease after menopause
Thank You