Endometriosis and adenomyosis

gynecology lecture

1. Endometriosis and adenomyosis Gaya 

2. “Presence of endometrial tissue other than the lining of endometrial cavity “ Common in reproductive age 1-2 % Most common benign gynaecological condition ,it is oestrogen depend and its resolve after menopause.

3. Commonly occur in pelvic Ovaries Uterosacral ligament Pouch of D ouglas Lateral pelvic wall Ovarian fossa

4. Extra pelvic Surgical scars Umbilicus Rectum Pleura Bladder

5. Endometrial tissue respond to cyclical hormonal changes and therefore undergoes cyclical bleeding and local inflammatory reaction . Repeat bleeding and healing cause fibrosis This cyclical damage cause adhesion between associated organs causing pain and infertility

6. Ovaries endometriomas occurs due to accumulation of blood as a result of repeated sheading of the endometrial surface This blood turns brown and resemble chocolate colour therefore called as chocolate cyst

7. Endometrioma : : Part of the condition known as endometriosis. Endometrioma is a type of cyst formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain associated with menstruation. Endometriosis is the presence of endometrial glands and tissue outside the uterus. Women with endometriosis may have problems with fertility. Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches.

8. Surgical management of endometriomas drained laparoscopically and the cyst wall can be excised . In situation where the cyst wall cannt be peeled off it can be diathermised . It is not recommended to use diathermy in women who are planning to conceive bacause of heat damage to ovaries

9. Etiology of endometriosis Etiology is unknown There are several theories 1) Implantation theory Direct implantation of endometrial tissue can grow in the newly implanted tissue such as in scar endometriosis

10. 2) Retrograde menstruation ( sampson’s theory) Endometrial cells which fall with menstrual blood into the pelvis can implant and grow in new sites. That’s why this is common in ovaries POD lateral pelvic wall 3) Coelomic metaplasia theory Coelomic epithelium can undergo metaplastic change in to endometrial tissue. This theory can explain endometriosis in pleura and peritoneal cavity.

11. 4) Vascular and lymphatic spread Vascular and lymphatic embolization of endometrial tissue can explain occurrence of endometriotic deposits in usual site outside the peritoneal cavity

12. American Fertility Association classified endometriosis in to 4 stage – mild/minimal/moderate/sever base upon How deep the peritoneal and ovarian endometriosis is How badly the POD is obliterate due to adhesion How dense the adhesions are on each tube and ovary

13. S ymptoms Sever cyclic non colicky pelvic pain (pain typically starts with or after the onset of menses and out lasts the period . Dysmenorrhea Deep dyspareunia- due to presents of endometrial tissues in pouch of Douglas

14. Pelvic pain may be associated with irritable bowel syndrome If distinct site affected can cause local symptoms Cyclic epistaxis with nasal passage deposit cyclical rectal bleeding with bowel deposits

15. Physical examination Bimanual vaginal examination very helpful to diagnosis On speculum examination Purplish endometriotic nodules may be visible in the posterior fornix Tender nodules felt along utero-sacral ligament Tender fornices and pouch of Douglas and adnexal mass or fixed retroverted uterus.

16. Sometimes palpable mass can be felt in adnexae if there are adhesion or endomertiomas

17. Investigation CA 125 level is raised in endometriosis It can be diagnosis by the TV-USS –detect gross endometriosis involving the ovaries ( endometrioma ) .In smaller USS is of limited value MRI detect >5mm in size particularly in deep tissue (rectovaginal septum)

18. Laparoscopy Gold standard of diagnosis is laparoscopy. Typical endometriotic deposits can be seen on laparoscopy with adjacent scarring of the tissue. Depend on experience of laparoscopist -base on the accuracy of visual diagnosis of endometriotic lesion . Lesion can be red .puckered . Black ‘matchstick’ or white fibrous lesion

19. a)Red lesion in peritoneum b)Black ‘matchstick’ lesions a b

20. c)White fibrous lesion

21. Management Ei medical or surgical .No definitive cure is available since the etiology of the disease is not clearly understood yet Treatment should therefore be tailored for the individual according to her age, symptoms, extent of the disease and her desire for future childbearing.

22. Medical management Principle is to create a period of amenorrhoea so that endometriosis tissue will undergo atropic changes and endometriosis will undergo regression This can be achieved by either creating a situation of pseudo-pregnancy or post menopause

23. Non-steroidal anti-inflammatory drugs (NSAIDs) are potent analgesics and are helpful in reducing the severity of dysmenorrhoea and pelvic pain .( The additional use codeine/opiates should be avoided as the coexisting irritable bowel symptoms can be worsened,exacerbating pelvic pain symptoms ) 2) Progesterone injection in high dose . Depo- provera is usually given in a dose of 150 mg IM every 4 weekly or continue oral tablet .use of levonorgestrel IUD effective

24. 3) OCP can be given continuously without the dummy tablets so there is no breakthrough bleeding for minimal 6 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.

25. 4) Danozol which has antiestrogenic properties is given to create post menopausal changes leading to endometrial atrophy There are androgenic side effects like weight gain ,acne , hirsutism , can limit its use. 5) Gonadotrophin-releasing hormone agonists (GnRH-A) are as effective as danazol in relieving the severity and symptoms of endometriosis by giving hypoestronic change

26. These can be administered as nasal spray or IM depot preparation .long term therapy cause menopausal effects like osteoporosis hot flush and night sweating like. The administrate low dose oestrogen therapy (HRT) –addback is given to prevent this

27. Surgical management Conservative surgery Laparoscopic surgery with techniques such as diathermy , laser vaporization , or excision has become the standard for surgical management. In mild to minimal endometriosis purple –brown spots can be seen in pelvis with scarring and puckering of the adjacent tissue . These are called ‘café-au- lait spots.

28. When surgery is done foe women with subfertility adhesiolysis is performed to make the tube and ovaries mobile .it is also important to clear the POD of adhesion Patient who complaining subfertility .fertility treatment should proceed immediately following surgical clearance

29. Aim of treatment is to make the patient pregnant before the adhesion formation and impair the tubal motility .so medical treatment for endo. Not recommend after surgery . Since pregnancy is the nature sure for endometriosis any women with evidence of endometriosis should be encouraged to get married and pregnat early

30. Definitive treatment Sever symptoms and progressive disease or in women whose families are complete hysterectomy and B/L salphingo –oophorectomy which is usually curative . HRT 6 month following surgery

31. Adenomyosis It is disorder which is endometrial gland found deep within the myometrium , Etiology yet unknown Patients are usually multiparous and diagnosis in their late 30s or early 40s Patients are present with increasing sever secondary dysmenorrhea and increasing menstrual blood loss

32. On examination find bulky and sometimes tender ‘boggy’ uterus . USS examination of uterus may be helpful in diagnosis –shows haemorrhage filled ,distended endometrial glands ,some times irregular nodules development can be seen. (similar to fibroid ) MRI is the more definitive investigation of choice as it provides excellent image of myometrium and endometrium and areas of adenomyosis

33. MRI images of adenomyosis .

34. Conservative medical and surgical treatment poorly response Any treatment which induce amenorrhea will be helpful. –relive pain and excessive bleeding symptoms rapidly return in the majority of patients, and hysterectomy remains the only definitive treatment.