Endometriosis and Adenomyosis

• Endometriosis


  Chronic disease marked by the presence of endometrial tissue (glands and stroma) outside the endometrial cavity
• Endometriosis


  • Most common sites are the ovary and the pelvic peritoneum including the anterior and posterior cul de sacs
  • Other common sites include the posterior uterus and broad ligaments, the uterosacral ligaments, fallopian tubes, colon, and appendix
• Theories about the etiology of endometriosis

  1. Halban theory: endometrial tissue is transported via the lymphatic system

  2. Meyer theory: multipotential cells in peritoneal tissue undergo metaplastic transformation

  3. Sampson theory: endometrial tissue is transported through the fallopian tubes during retrograde menstruation
• Altered immune system in women with endometriosis

  • Less likely to recognize and attack ectopic endometrial implants
  • Increased concentration of inflammatory cells in the peritoneum that contribute to the growth and stimulation of the endometrial implants
• Endometrial implants cause symptoms by disrupting normal tissue, forming adhesions and fibrosis, and causing severe inflammation
• The severity of symptoms does not necessarily correlate with the amount of endometriosis
• Prevalence of endometriosis


  Estimated between 10% and 15%
• Endometriosis is the single most common reason for hospitalization of women of reproductive age
• Risk factors for endometriosis

  • Nulliparity
  • Early menarche
  • Prolonged menses
  • Müllerian anomalies
  • First-degree relatives with endometriosis
  • Autoimmune inflammatory disorders
• Endometriosis is identified less often in black and Asian women
• Hallmark of endometriosis


  Cyclic pelvic pain beginning 1 or 2 weeks before menses, peaking 1 to 2 days before the onset of menses, and subsiding at the onset of menses or shortly thereafter
• Symptoms associated with endometriosis

  • Dysmenorrhea
  • Dyspareunia
  • Abnormal bleeding
  • Bowel and bladder symptoms
  • Subfertility
• Over 75% of women with symptomatic endometriosis will have pelvic pain and/or dysmenorrhea
• Endometriosis is a cause of infertility
• Physical findings in early endometriosis

  Subtle or nonexistent
• Physical findings in more disseminated endometriosis

  • Uterosacral nodularity and tenderness on rectovaginal examination
  • Fixed retroverted uterus
  • Pain with movement of the uterus
  • Tender, fixed adnexal mass
• The only way to definitively diagnose endometriosis is through direct visualization with laparoscopy or laparotomy
• Appearance of endometrial implants

  • Rust-colored to dark brown powder burns
  • Raised, blue-colored mulberry or raspberry lesions
  • Surrounded by reactive fibrosis that can lead to dense adhesions
• Endometriomas


  Large cystic collections of endometriosis filled with thick, dark, old blood and debris
• Classification of endometriosis


  • Minimal
  • Mild
  • Moderate
  • Severe
• Differential diagnosis for endometriosis

  • Pelvic inflammatory disease
  • Adenomyosis
  • Irritable bowel syndrome
  • Interstitial cystitis
  • Pelvic adhesions
  • Functional ovarian cysts
  • Ectopic pregnancy
  • Ovarian neoplasms
• Medical treatments for endometriosis

  • NSAIDs
  • Cyclic or continuous estrogen-progestin contraceptives
  • Menstrual suppression with progestins
  • Danazol
  • GnRH agonists
  • Aromatase inhibitors
• Add-back therapy


  Adds a small amount of progestin with or without estrogen to GnRH agonists to minimize symptoms caused by estrogen deficiency
• Surgical treatments for endometriosis

  • Conservative: laparoscopy and fulguration or excision of visible endometrial implants
  • Definitive: total hysterectomy and bilateral salpingo-oophorectomy
• Laparoscopic cystectomy for endometriomas


  Removal of as much of the cyst wall as possible
• Pregnancy rates after conservative surgical treatment depend on the extent of the disease at the time of surgery
• Conservative surgical therapy


  Typically involves laparoscopy and fulguration or excision of any visible endometrial implants
• Endometriomas


  Best treated using laparoscopic cystectomy with removal of as much of the cyst wall as possible
• With conservative therapy, the uterus and ovaries are left in situ
• Pregnancy rate after conservative surgical treatment

  Depends on the extent of the disease at the time of surgery
• Conception Rates after Ablation of Endometrial Implants

  • Mild disease (stage 1 & 2): 75%
  • Moderate disease (stage 3): 50-60%
  • Severe disease (stage 4): 30-40%
• Definitive surgical therapy


  Total hysterectomy and bilateral salpingo-oophorectomy, lysis of adhesions, and removal of any visible endometriosis lesions
• Definitive surgical therapy is reserved for cases in which childbearing is complete and for women with severe disease or symptoms that are refractory to conservative medical or surgical treatment
• If postsurgical hormone replacement therapy is started after hysterectomy and oophorectomy, some providers will still employ combination hormone therapy due to the theoretical possibility of stimulating transformation of residual implants into an endometrial cancer by the use of estrogen-only replacement therapy
• Adenomyosis


  Extension of endometrial tissue into the uterine myometrium leading to abnormal bleeding and pain
• Adenomyoma


  A well-circumscribed collection of endometrial tissue within the uterine wall
• Adenomyosis and endometriosis are two distinct and different clinical entities
• Cause of adenomyosis


  High levels of estrogen stimulate hyperplasia of the basalis layer of the endometrium, leading to the endometrial cells invading the myometrium
• Adenomyosis occurs most frequently in parous women, and it is thought that subclinical endomyometritis may be the first insult to the endometrial-myometrial barrier
• Another theory is that adenomyosis develops de novo from metaplastic transformation of müllerian rests cells located within the myometrium