1. Endometriosis and Adenomyosis

2. Definitions
Endometriosis: presence of ectopic endometrial glands and stroma outside of the uterus
Adenomyosis: presence of ectopic endometrial glands and stroma in the myometrium of the uterus
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3. Incidence Endometriosis Adenomyosis
More common in younger women (20-30s)
More common in nullparous women
Adenomyosis
More common in older women (30-50s)
More common in parous women
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4. Pathogenesis
Implant theory: tissue travels via retrograde menstruation or surgery / deliveries
Lymphatic / vascular theory: explains distant location
Metaplasia theory: undifferentiated cells transform into endometrial tissue
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5. Genetic Factors 1st degree relative - 7% rate
General population - 1% rate
↑ Rate w/ twins
No genetic tests
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6. Locations Most Common Anterior / posterior cul de sac Broad ligament
Uterosacral ligament
Fallopian tubes
Sigmoid colon
Appendix
Round ligament
Less Common
Vagina
Cervix
Small intestines
Abdominal scars
Bladder
Infrequent
Breast
Pancreas
Liver
Gallbladder
Kidneys
Legs / arms
Lungs
CNS
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7. Clinical Presentation
Dysmenorrhea
Pelvic pain
Dyspareunia
Constipation
Dyschezia
Infertility
Pelvic mass
Dysuria
Hematuria
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8. Physical Exam Findings
Tender nodules in uterosacral ligament
Fixed retroverted uterus
Laterally displaced cervix
Tender pouch of Douglas
Pain w/ movement of uterus
Palpable pelvic mass
Vaginal / cervical lesions
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9. Physical Exam Findings
Tender nodules in uterosacral ligament
Fixed retroverted uterus
Laterally displaced cervix
Tender pouch of Douglas
Pain w/ movement of uterus
Palpable pelvic mass
Vaginal / cervical lesions
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10. Evaluation H&P: can start benign treatment
Pelvic U/S: can detect ovarian endometriomas nodules
Laparoscopy
Visualize: satisfactory diagnosis
Biopsy: definitive diagnosis
Endometrial glands
Stroma
Hemosiderin-laden macrophages
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11. Treatment - Medical NSAIDs OCPs
GnRH agonist (eg Leuprolide) ± add on therapy
Only 6 months at a time
Osteoporosis + vasomotor symptoms
Progestin (eg Depo-Provera or medroxyprogesterone)
Weight gain, irregular bleeding, depression
Danazol
hyperandrogenism + hyporestrogenism
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12. Treatment - Surgery Conservative Definitive Ablation of implants
Preserves fertility
Definitive
BSO + TAH (bilateral salpingo-oophorectomy + total abdominal hysterectomy)
Lose fertility
Early menopause
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13. Definitions
Endometriosis: presence of ectopic endometrial glands and stroma outside of the uterus
Adenomyosis: presence of ectopic endometrial glands and stroma in the myometrium of the uterus creating a symmetrically enlarged boggy globular uterus
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14. Clinical Presentation
Menorrhagia
Dysmenorrhea
Diffusely enlarged boggy globular uterus
Rarely normal uterus w/ nodules (adenomyoma)
Use U/S or MRI to differentiate from leiomyoma
Often coexists w/ uterine leiomyomas and/or endometriosis
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15. Evaluation History and physical exam Pregnancy test TVUS / MRI
Hysterectomy (for definitive diagnosis)
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16. Treatment NSAIDs, OCPs, GnRH agonist, Progestins
Treats menorrhagia + dysmenorrhea
Definitive surgery: hysterectomy
Conservative surgery: endomyometrial ablation
uterine artery embolization
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