Endometriosis and Adenomyosis
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 learnobgyn.com
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 learnobgyn.com
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 learnobgyn.com
Genetic Factors 1st degree relative - 7% rate General population - 1% rate ↑ Rate w/ twins No genetic tests learnobgyn.com
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 learnobgyn.com
Clinical Presentation Dysmenorrhea Pelvic pain Dyspareunia Constipation Dyschezia Infertility Pelvic mass Dysuria Hematuria learnobgyn.com
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 learnobgyn.com
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 learnobgyn.com
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 learnobgyn.com
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 learnobgyn.com
Treatment - Surgery Conservative Definitive Ablation of implants Preserves fertility Definitive BSO + TAH (bilateral salpingo-oophorectomy + total abdominal hysterectomy) Lose fertility Early menopause learnobgyn.com
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 learnobgyn.com
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 learnobgyn.com
Evaluation History and physical exam Pregnancy test TVUS / MRI Hysterectomy (for definitive diagnosis) learnobgyn.com
Treatment NSAIDs, OCPs, GnRH agonist, Progestins Treats menorrhagia + dysmenorrhea Definitive surgery: hysterectomy Conservative surgery: endomyometrial ablation uterine artery embolization learnobgyn.com