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 20s and 30s

tends not to occur before menarche or after menopause

major cause of infertility

Theories for Etiology

Sampsons theory of retrograde menstruation

Halbans lymphatic spread theory
Meyers 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 premenstrual 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