resident presentation

1. ENDOMETRIOSIS AND
ADENOMYOSIS
Prepared by
Leon SEWUMUNTU

2. Definition
• endometriosis is defined as presence of functioning
endometrial glands and stroma outside the uterus

3. introduction
• The lesions are typically located in the pelvis but can
occur at multiple sites
• can cause dysmenorrhea, dyspareunia, chronic pain, and
infertility.
• Cyclic hormones stimulate growth but continuous
hormones suppress it.

4. Prevalence
• the prevalence has been increasing both in terms of real and
apparent.
• The real one is due to delayed marriage, postponement of first
conception and adoption of small family norms.
• The apparent one : diagnostic laparoscopy as well as
increased awareness.
• The prevalence of endometriosis ranges from 2-50% of
reproductive aged women.
• 71-87% of women with chronic pelvic pain.
• high amongst the infertile women (30–40%)
• with an affected first-degree relative :7 to 10-fold increased risk
Endometriosis Olivia J Carpinello, MD, Lauren W Sundheimer, MD, Connie E
Alford, MD, Robert N Taylor, M.D., PhD., and Alan H DeCherney, MD.
2017

5. common pelvic sites in decreasing
order
•Ovary and ovarian fossa – 67 and 32 percent
•Anterior and posterior cul-de-sac
•Posterior broad ligaments
•Uterosacral ligaments – 46 percent
•Pouch of Douglas – 30 percent
•Bladder – 21 percent
•Fallopian tubes
•Sigmoid colon
•Appendix
•Round ligaments
•Other - vagina, cervix, rectovaginal (or retrovaginal) septum,
cecum, ileum, inguinal canals, perineal scars, ureters, and
umbilicus

6. Extra-pelvic sites
• An endometrioma can arises in the anterior abdominal
wall, usually in the vicinity of a surgical incision.
• although these lesions can occur in individuals with no
history of surgery.
• Rarely, in the breast, pancreas, liver, gallbladder, kidney,
urethra, extremities, vertebrae, bone, peripheral nerves,
spleen, diaphragm, central nervous system, hymen and
lung

7. Pathogenesis
• Retrograde Menstruation (Sampson’s theory): flow of
menstrual blood through the uterine tubes.
• Because it is a functioning endometrium it bleeds on
monthly basis and can create adnexal enlargement
known as endometrioma or chocolate cyst
• The endometrial fragments get implanted in the peritoneal
surface of the pelvic organs
• This theory fails to explain the endometriosis at distant
sites.

8. How to support the retrograde menses
theory
• observations made during surgeries in the 1920’s that many
women shed endometrial debris through their fallopian tubes
into the peritoneum during menstruation .
• endometrial tissue will grow if placed ectopically.
• most commonly in the gravitationally dependent parts of the
pelvis
• the incidence is significantly increased in genital tract
obstructions.
• but retrograde menstruation has been shown in 76-90%
women, so additional factors:
• the amount of endometrial debris, the immunocompetency of
the woman to clear the debris, and the molecular
abnormalities/properties inherent in the ectopic tissue.

9. Coelomic metaplasia(Meyer’s theory)
• cells from both the peritoneum and endometrium are
derived from a common embryological precursor: the
coelomic cell.
• Chronic irritation of the pelvic peritoneum by the
menstrual blood may cause coelomic metaplasia which
results in endometriosis.
• Alternatively, the müllerian tissue remnants may be
trapped within the peritoneum could undergo metaplasia
and be transformed into endometrium.
• This theory can explain endometriosis of the abdominal
viscera, the rectovaginal septum and the umbilicus

10. Direct Implantation
• the endometrial or decidual tissues start to grow in
susceptible individual when implanted in the new sites.
• Such sites are abdominal scar following hysterotomy,
caesarean section, tubectomy and myomectomy.
• Endometriosis at the episiotomy scar, vaginal or cervical
site can also be explained with this theory.

11. Halban’s theory
• suggests that distant lesions are established by
the hematogenous or lymphogenous spread of
viable endometrial cells.
• explains rare endometriotic lesions in the brain or
lung
• it does not explain the gravitationally-dependent
location of most foci of endometriosis.

12. Increase risks
family history
nulliparity
early menarche or late menopause,
shorter menstrual cycles heavy menstrual bleeding
obstruction of menstrual outflow
taller height and lower body mass index.

13. Reduce risk
• multiple births
• extended intervals of lactation
• late menarche (after age 14 years)

14. Symptoms
• About 25 percent of patients with endometriosis have no
symptom
• Symptoms are not related with extent of lesion.
• Even when the endometriosis is widespread, there may
not be any symptom
• there may be intense symptoms with minimal
endometriosis.
• Depth of penetration is more related to symptoms rather
than the spread.
• Lesions penetrating more than 5 mm are responsible for
pain, dysmenorrhea and dyspareunia.

15. pain
• The pain is most often cyclic, but may also be chronic in
nature.
• The pain usually begins just before menses and
continues throughout the duration of menstrual flow.
• Dysmenorrhea and deep dyspareunia are the most
common pain complaints with 70% and 30% prevalence,
respectively .
• Dysuria, dyschezia, and intermenstrual pelvic pain are
less common and are associated with bladder or bowel
lesions.

16. Dysmenorrhea (70%)
• There is progressively increasing secondary
dysmenorrhea.
• The pain starts a few days prior to menstruation; gets
worsened during menstruation and takes time, even after
cessation of period.
• Increased secretion of PGF 2α, thromboxane β2 from
endometriotic tissue is the cause of pain.

17. Proximal (deep) dyspareunia
lesions can occur on the uterosacral and cardinal
ligaments, pouch of Douglas, posterior vaginal fornix, and
anterior rectal wall
Distal (superficial) dyspareunia
can result from lesions of the cervix , hymen , perineum ,
and episiotomy scars

18. Abnormal menstruation (20%):
• Menorrhagia is the predominant abnormality.
• If the ovaries are also involved, polymenorrhea or
epimenorrhagia may be pronounced.
• There may be premenstrual spotting.

19. Infertility (40–60%):
• Whether endometriosis causes infertility or infertility
produces endometriosis is not clear.
• Endometriosis is found in 20–40 percent of infertile
women
• 40–50 percent patients with endometriosis suffer from
infertility.
• The monthly fecundity rate in normal couples is 15-20%
• with untreated endometriosis is 2-10%.

20. Chronic Pelvic Pain
• The cause include:
(i) Inflammation in the peritoneal implants and release of
PGF, and also due to adhesions and ovarian cysts.
(ii) Action of inflammatory cytokines released by the
macrophages.
(iii) Invasion of nerves or involvement of bladder and bowel.
• The Sometimes, the pain may be acute due to rupture of
chocolate cyst

21. Symptoms as predictor of
endometriosis type con’t
Abdominal wall pain
• Patients with endometriosis of the abdominal wall
• the pain may be cyclic with menses or continuous
• Bleeding of mass can occur
Chest pain, hemoptysis, hemo or pneumothorax ,
scapular or cervical (neck) pain.
• Individuals with thoracic endometriosis

22. Symptoms as predictor of
endometriosis type con’t
• Urinary frequency, urgency, and/or painful micturition
• Bladder endometriosis typically presents with nonspecific
urinary symptoms .
• Symptoms can be worsened with menses.
• Ureteral endometriosis can be asymptomatic or
associated with colicky flank pain or gross hematuria

23. Gut: The rectum, sigmoid colon or even
the small intestine
• The mucosa is not involved, a differentiating feature from
malignancy.
• The patient complains of periodic colicky pain on
defecation or at times bleeding per rectum specially
during periods.
• There may be even features of subacute intestinal
obstruction. Rectal examination and investigations like
sigmoidoscopy and barium enema confirm the diagnosis.

24. Natural history
• studies where second-look laparoscopy was performed 6
to 12 months after a diagnostic laparoscopy confirmed
endometriosis, disease progressed in 29 to 45 percent of
untreated women, regressed in 22 to 29 percent, and
remained stable in 33 to 42 percent
• In a prospective study that followed 88 asymptomatic
women with rectovaginal disease for one to nine years,
fewer than 10 percent of the women had disease
progression
• Factors that cause endometriosis to progress, regress, or
remain stable are not yet known.

25. EVALUATION
Suggestive findings
focal tenderness on vaginal examination,
nodules in the posterior fornix,
adnexal masses, and immobility or lateral placement of the
cervix or uterus .
Rarely, an endometriosis lesion will be visualized on the
cervix or vaginal mucosa.
Lack of findings
While physical examination findings are helpful, the
examination can also be normal; lack of findings does not
exclude the disease.

26. Imaging
• Ultrasonography is not much helpful to the diagnosis.
• TVS can detect ovarian endometriomas.
• Transvaginal (TVS) and Endorectal ultrasound are found
better for rectosigmoid endometriosis.
• CT is better compared to ultrasonography in the
diagnosis.
• MRI is useful for deep infiltrating endometriosis
• Colonoscopy, rectosigmoidoscopy and cystoscopy are
done when respective organs are involved.
• Laparoscopy is the gold standard, Confirmation is done
by double puncture laparoscopy or by laparotomy.

27. Presumptive clinical diagnosis
The combination of symptoms, signs, and imaging findings.
Components of a nonsurgical diagnosis include :
●Ultrasonographic finding of ovarian endometrioma
●Visual inspection of the posterior vaginal fornix and biopsy
of rectovaginal lesions
●Cystoscopic evaluation and biopsy of visible detrusor
lesions
●Physical examination findings of rectovaginal
endometriosis that are confirmed with imaging

28. Definitive surgical diagnosis
Surgery, which is usually performed laparoscopically,
allows both definitive diagnosis and treat
Indications – Typical indications for surgical exploration
include:
•Evaluation of severe pain or other symptoms that limit
function
•Persistent pelvic pain that does not respond to medical
therapy
•Treatment of anatomic abnormalities, such as
symptomatic ovarian cysts, rectovaginal nodules, or
bladder lesions.

29. con’t
• Tissue biopsy versus visualization
• Endometriosis is definitively diagnosed by histologic
evaluation of a lesion biopsied during surgery (typically
laparoscopy)
• visual confirmation of endometriosis without biopsy is
considered diagnostic
• visual confirmation alone is impacted by the stage and
location of endometriosis as well as surgeon's expertise.

30. Visual lesions but negative histology
Individuals with classic endometriosis lesions at
laparoscopy but negative histology are treated for
endometriosis because negative biopsies can result from
inadequate sampling and do not definitively exclude
disease

31. Staging
• The diagnosed endometriosis should be appropriately
staged based on laparoscopic findings.
• To predict prognosis
• To choose therapy
• To evaluate the treatment protocol.

33. Treatment OF ENDOMETRIOSIS
Preventive
• To avoid tubal patency test immediately after curettage or
around the time of menstruation
• Forcible pelvic examination should not be done during or
shortly after menstruation

34. Curative treatment of endometriosis
The objectives are:
• To abolish or minimize the symptoms
• To improve the fertility
• To prevent recurrence.
Treatment options for Pelvic Endometriosis :
• Expectant Management (observation only)
• Medical Therapy: Hormones , Others
• Surgery: Conservative , Definitive
• Combined Therapy: Medical and Surgical

35. Expectant Treatment
• It is not possible to predict in which woman it will progress.
• Some form of treatment is often needed regardless of the
clinical profile and to arrest the progress of the disease.
• However, in women with minimal to mild endometriosis role of
any treatment is controversial.
Case selection for expectant treatment
• Minimal endometriosis with no other abnormal pelvic finding
• Unmarried
• Young married who are ready to start family
• Approaching menopause

36. Protocols for Expectant Management
• Observation with administration of non-steroidal anti-
inflammatory drugs or prostaglandin synthetase inhibiting
drugs are used to relieve pain
• The married women are encouraged to have conception.
• Pregnancy usually cures the condition
• This is due to absence of shedding and decidual changes
in the ectopic endometrium causing its necrosis and
absorption

37. Hormonal Treatment
• The aim of the hormonal treatment is to induce atrophy of
the endometriotic implants.
• It should be considered suppressive rather than curative
because of high recurrence rate.
• The mechanism of endometrial atrophy is either by
producing ‘pseudopregnancy’ (combined oral pills) or by
‘pseudomenopause’ (Danazol) or by ‘medical
oophorectomy’ (GnRH agonists).
• The drugs used are combined estrogen and progestogen
(oral pill), progestogens, danazol and GnRH analogues.

38. Hormonal Treatment con’t
Combined estrogen and progesterone
• causes endometrial decidualization and atrophy . It relieves
dysmenorrhea.
• Anastrozole
• an aromatase inhibitor is found to reduce the growth and pain
of endometriosis .
• Progestogens
• It causes decidualization of endometrium and atrophy .
• High doses may suppress ovulation and induce amenorrhea
• Levonorgestrel-releasing-IUCD
reduce dysmenorrhea, pelvic pain, dyspareunia and
menorrhagia significantly.
It is specially useful for rectovaginal endometriosis

39. Hormonal Treatment con’t
• Danazol
• Danazol therapy is to be started from the day 5 of the
menstrual cycle.
• The patient should use barrier methods of contraception
to avoid virilization of a female fetus in accidental
pregnancy.
• Resolution of endometriotic lesions has been seen in
about 80% of cases but the recurrence rate is high (40%).
• Gestrinone has got the same mechanism of action like
that of danazol.
• The side effects are less than danazol. Administration is
simple, twice a week .

40. Hormonal Treatment con’t
GnRH analogues (leuprolide or Lupron)
• When used continuously act as medical oophorectomy, a
state of hypoestronism and amenorrhea.
• The goal is to maintain a reduced level of serum estrogen
(30–45 pg/mL) so that growth of endometriosis is
suppressed.
• Long-term therapy (more than 6 months) should be
avoided

41. • Results: The efficacy of the hormone therapy is judged by
relief of symptoms, reduction of the volume of the lesions
as revealed by second look laparoscopy,
• improvement of fertility
• prevention of recurrence.
• For quick relief of symptoms and reduction of the volume
of the lesion, GnRH analogues are the best.
• Progestogens take some time to achieve these
objectives.
• Danazol is placed midway between the two.
• Overall recurrence rate is about 40 percent after 5 years.

42. SURGICAL MANAGEMENT OF
ENDOMETRIOSIS
Indications
• Endometriosis with severe symptoms unresponsive to
hormone therapy.
• Severe and deeply infiltrating endometriosis to correct the
distortion of pelvic anatomy.
• Endometriomas of more than 1 cm.
Surgery may be conservative or definitive.
Conservative surgery is planned to destroy the
endometriotic lesions in an attempt to improve the
symptoms (pain, subfertility) and at the same time to
preserve the reproductive function.

43. Definitive surgery:
• It is indicated in women with advanced stage
endometriosis where there is:
• (i) No prospect for fertility improvement.
• (ii) Other forms of treatment have failed.
• (iii) Women with completed family.
• Definitive surgery means hysterectomy with bilateral
savlpingo-oophorectomy along with resection of the
endometrial tissues as complete as possible.

44. Combined Medical and Surgical
• Preoperative hormonal therapy aims at reduction of the
size and vascularity of the lesion which facilitate surgery.
The idea of postoperative hormonal therapy is to destroy
the residual lesions left behind after surgery and to control
the pain.
• But it does not improve fertility.
• Duration of therapy is usually 3–6 months preoperatively
and 3–6 months postoperatively.
• The cumulative probability of pregnancy at 3 years
following laparoscopic surgery was 47% (51% for stage I,
45% of stage II, 46% of stage III and 44% for stage IV).
• Overall risk of recurrence is 40% by 5 years time.

45. ENDOMETRIOSIS AT SPECIAL SITES
• Abdominal scar ,Umbilicus ,Bladder and ureter Gut
,Cervix and vagina ,Lung Scar :
• It usually manifests following abdominal hysterotomy,
cesarean section, myomectomy or even tubectomy.
• The patient complains of painful nodular swelling over or
adjacent to the scar which increases in size and often
bleeds during periods.
• Treatment is by excision. Hormone therapy is ineffective

46. Bladder and ureters
The patient complains of dysuria, frequency, hematuria
and lower abdominal pain specially during periods.
Cystoscopic examination reveals blue area of the mucosa.
IVP may reveal ureteric stricture and hydroureteric or even
hydronephrotic changes on the affected side.
Local excision of the bladder wall and repair should be
done.
In ureteric involvements, the segment of the ureter is to be
excised followed by implantation of the ureter to the
bladder.

47. Lung, pleura, and brain are the rare sites
• This may cause catamenial pneumothorax or seizures
during mensens.
• Treatment:
• Hormone treatment may be effective. If it fails, surgery
may have to be done
• Cervix and vagina: The lesions are usually due to
implantation of the endometrium over the trauma inflicted
at operation or following delivery. The only complaint may
be dyspareunia. The lesion is revealed by speculum
examination.
• Confusion may arise with carcinoma cervix. There is,
bleeding on touch in carcinoma. Confirmation is done by
biopsy. Treatment by hormone is ineffective.