painful, mensteruation

1. ENDOMETRIOSIS AND
ADENOMYOSIS
Lectures on Gynecology
Dr Magda Helmi

2. Introduction
Endometriosis is a common
condition which is defined
as endometrial tissue lying
outside the endometrial
cavity. It is usually found
within the peritoneal cavity,
predominantly within the
pelvis, commonly on the
uterosacral ligaments. It can
also be found in other sites
such as umbilicus,
abdominal scars, nasal
passages and pleural cavity.

3. Aetiology
Endometriosis occurs in approximately 1-2 per
cent of women of reproductive age.
It is the most common benign gynaecological
condition, estimated to be present in between
10 and I5 per cent of women.
It is a condition that is oestrogen dependent
theories that explains the
etiology of endometriosis:
Menstrual regurgitation and implantation
Coeiomic epithelium transformation
Meyer’s `coelomic metaplasia theory
Genetic and immunological factors
Vascular and lymphatic spread

4. Diagnoses
A laparoscopy or laparotomy
procedure is used when trying
to diagnose endometriosis.
Ultrasounds, MRIs, and CAT
scans are not conclusive when
diagnosing endometriosis.
Endometriosis can only be
diagnosed through surgery.

5. Clinical features
Symptoms: Symptoms may begin a few days before
menses starts until the end of menses.
Dysmenorrhea
Infertility
Painful sexual intercourse
Painful bowel movements
Fatigue
Heavy or irregular bleeding
Pain during ovulation
Gastrointestinal problems
Painful urination
Lower back pain
It is well recognized that there is a lack of correlation
between extent of disease and the intensity of
symptoms.
Chronic or intermittent pelvic pain
Classical clinical features are severe cyclical non colicky
pelvic pain restricted to around the time of
menstruation, sometimes associated with heavy
menstrual loss.

6. sit symptoms
Female reproductive tract Dsymenorrhoea
Lower abdominal and pelvic pain
Dyspareunia
Rupture/torsion endometrioma
Low back pain
Infertility
Urinary tract Cyclical haematuria/dysuria
Ureteric obstruction
Gastrointestinal tract Dyschezia (pain on defecation)
Cyclical rectal bleeding
Obstruction
Surgical scars/umbilicus Cyclical pain and bleeding
Lung Cyclical haemoptysis
Haemopneurnothorax
Symptoms of endometriosis in relationship to site of lesion

7. Physical examination
It can be suspected by clinical findings on vaginal
examination:
Thickening or nodularity of the uterosacral ligaments,
Tenderness in the pouch of Douglas,
An adnexal mass or a fixed retroverted uterus.
However, pelvic tenderness alone is nonspecific and
differential diagnoses for restricted mobility of the uterus
include chronic pelvic inflammatory disease and uterine,
ovarian or cervical malignancy. In these conditions, other
suggestive features are usually present.

8. Investigations
Ultrasound
Transvaginal ultrasound
can detect gross
endometriosis involving
the ovaries
(endometriomas or
chocolate cyst).
In smaller lesions, US is of
limited value.
However, the use of
ultrasound can be
reassuring by excluding
gross disease.

9. Investigations
Magnetic resonance imaging
MRI is essential for an accurate differential
diagnosis.
MRI can evaluate areas otherwise inaccessible
by laparoscopy, identifying and evaluating the
extent of lesions in the sub–peritoneal region
and in the presence of dense adhesions.
MRI plays an essential role in the preoperative
evaluation of patients with deep pelvic
endometriosis.

10. Investigations
laparoscopy
The advantage of
laparoscopy is that it
affords concurrent
excision of
endrometriotic
lesions and also a
staging of the disease.

11. Stage Progression Tissue Description
I Minimal Presentation of 2-3 superficial implants.
II Mild Appearance of more implants that occur
Within deeper layers of tissue.
III Moderate Many deep implants in combination With minor/small endometriomas
on one or both ovaries. May also present filmy adhesions.
IV Severe Persistence of deep implants, enlargement of endometriomas on one or
both ovaries, development of dense adhesions.
Staging of the disease.

12. Infertility and endometriosis possible mechanisms
Ovarian function Luteolysis caused by prostaglandins F2
Oocyte maturation defects
Endocrinopathies
Luteinized unruptured follicle syndrome
Altered prolactin release
Anovulation
Tubal function Impaired fimbrial oocyte pick-up
Altered tubal motility
Coital function Deep dyspareunia - reduced
coital frequency
Sperm function Antibodies causing inactivation
Macrophage phagocytosis of spermatozoa
Early pregnancy failure Prostaglandin induced
Immune reaction
Luteal phase deficiency

13. Management
Patients with endometriosis are
often difficult to treat, not only from
a physical point of view, but also
often because of associated
psychological issues. Therapies
designed for long-term strategies
should be used.
Endometriosis is known to be a
recurrent disorder throughout the
whole of reproductive life and it is
impossible to guarantee complete
cure.

14. Medical therapy
Analgesics
Non-steroidal anti-inflammatory drugs (NSAIDs) are potent analgesics and are helpful in reducing the severity of
dysmenorrhoea and pelvic pain. However, they have no specific impact on the disease
Hormonal Drug Therapy:
Hormonal drugs are given to try to stop ovulation for as long as possible in order to keep the implants or lesions from being
aggravated. Most of these therapies can only be given for a limited amount of time, and the side effects can cause problems
for some women. Hormonal drug therapy is used to ward off symptoms and is often most effective when used after surgical
treatment has been done.
Combined oral contraceptive agents
Oral contraceptive agents can be used for diagnostic and therapeutic purposes. COC should be prescribed to be taken
continuously for an initial six- month period, If there is symptomatic relief with the continuous use of COC, then this therapy
should be continued indefinitely for up to several years or even longer until pregnancy is intended.
Progestogens
In those where there are risk factors for the use of OCC.
Danazol/gestrinone
The use of danazol and gestrinone, ovarian suppressive agents, are now not commonly used agents. Although effective, side
effects, such as androgen effects, for example weight gain, greasy skin and acne over long term (>six months), alterations in
lipid profiles or liver function, limit their use.
GnRH agonists.
Gonadotrophin-releasing hormone agonists Gonadotrophin-releasing hormone agonists GnRH-A) are as effective as danazol
in relieving the severity and symptoms of endometriosis and differ only in their side effect. These drugs induce a state of
pseudo-menopause.

15. Surgical Treatment
Laparoscopic Surgery
Laparoscopy is the most common procedure used to diagnose and remove mild to
moderate endometriosis.
Hysterectomy

17. Adenomyosis
The term adenomyosis is derived from the
Greek terms adeno- (meaning gland),myo-
(meaning muscle), and -osis (meaning
condition).
Previously named as endometriosis interna,
adenomyosis actually differs from
endometriosis and these two disease
entities are found together in only 10% of
the cases.

18. The condition is typically found in women between the ages of
35 and 50. Patients with adenomyosis can have painful and/or
profuse menses (dysmenorrheal & menorrhagia, respectively).
However, because the endometrial glands can be trapped in
the myometrium, it is possible to have increased pain without
increased blood. (This can be used to distinguish adenomyosis
from endometrial hyperplasia; in the latter condition,
increased bleeding is more common.)
In adenomyosis, basal endometrium penetrates into
hyperplastic myometrial fibers. Therefore, unlike functional
layer, basal layer does not undergo typical cyclic changes with
menstrual cycle.
Adenomyosis may involve the uterus focally, creating an
adenomyoma. With diffuse involvement, the uterus becomes
bulky and heavier.

19. The cause of adenomyosis is unknown, although it
has been associated with any sort of uterine trauma,
such as a caesarean section, tubal ligation, pregnancy
termination, and any pregnancy. It can be linked with
endometriosis, but studies looking into similarities
and differences between these two conditions have
conflicting results.
The differential of abnormal uterine bleeding includes
• endometrial polyps
• submucus fibroids
• endometrial hyperplasia
• endometrial carcinoma

20. Signs and symptoms
Some women with adenomyosis do not
experience any symptoms, while others may
have severe, debilitating symptoms. Intense
debilitating pain all the time and/or
•Acute & increasing pain at menstruation and
ovulation
•Strong 'contraction' feel of uterus
•Abdominal cramps
•A 'bearing' down feeling
•Pressure on bladder
•Dragging sensation down thighs and legs
•Heavy bleeding and flooding
•Large blood clots
•Prolonged bleeding i.e.; up to 8–14 days
hysrotoscopy

21. The uterus may be imaged
using ultrasound (US) or
magnetic resonance imaging
(MRI). A thickness of the
junctional zone greater than
10 to 12 mm (depending on
who you read) is diagnostic
of adenomyosis (<8 mm is
normal).
Conservative treatment
often consists of
anti-inflammatory
medications.
Hormonal manipulation.
Hormonal suppression
Hysterectomy may be
warranted in some cases,