الرحمن الله الرحمن بسم الله بسمالرحيمالرحيم

Endometriosis and Endometriosis and AdenomyosisAdenomyosis

By Dr. Sallama By Dr. Sallama KamelKamel

Endometriosis is defined asEndometriosis is defined as::

Presence of endometrial tissues ( superficial Presence of endometrial tissues ( superficial epithelium, glands and stroma ) in places epithelium, glands and stroma ) in places outside the uterine cavityoutside the uterine cavity..It is eitherIt is either::

11..External endometriosisExternal endometriosis::The endometriotic tissues present outside the The endometriotic tissues present outside the uterus (pelvis and other places)uterus (pelvis and other places)..

22..Internal endometriosis (Adenomyosis )Internal endometriosis (Adenomyosis )::The presence of endometriotic tissues inside The presence of endometriotic tissues inside the uterine wall within the myometriumthe uterine wall within the myometrium..

External EndometriosisExternal Endometriosis::

PrevalencePrevalence::

Endometriosis is a common and important Endometriosis is a common and important health problem of womenhealth problem of women..

It’s exact prevalence is unknown because It’s exact prevalence is unknown because surgery is required for diagnosissurgery is required for diagnosis..

It is estimated to be present in 3-10% of It is estimated to be present in 3-10% of women in the reproductive age group and 25-women in the reproductive age group and 25-35% of infertile women35% of infertile women..

PathogenesisPathogenesis::

The cause of endometriosis is unknownThe cause of endometriosis is unknown..Many theories exit to explain the Many theories exit to explain the development of the disease but no single development of the disease but no single theory can explain all sites of the diseasetheory can explain all sites of the disease..

11..Menstrual regurgitation and Menstrual regurgitation and implantationimplantation::

it has been suggested that endometriosis it has been suggested that endometriosis resulted from retrograde menstrual resulted from retrograde menstrual regurgitation of viable endometrial glands regurgitation of viable endometrial glands and tissue within the menstrual fluid and and tissue within the menstrual fluid and subsequent implantation on the peritoneal subsequent implantation on the peritoneal surfacesurface..

The prove for this theory is the presence of endometriosis The prove for this theory is the presence of endometriosis in women with associated abnormalities of the genital in women with associated abnormalities of the genital tract , causing obstruction of the vaginal outflow of tract , causing obstruction of the vaginal outflow of menstrual fluidmenstrual fluid..

22..Coelomic epithelium transformationCoelomic epithelium transformation::

There is a common origin for the cells lining the mullerian There is a common origin for the cells lining the mullerian duct, the peritoneal cells and the cells of the ovaryduct, the peritoneal cells and the cells of the ovary..

It has been suggested that these cells undergo de-It has been suggested that these cells undergo de-differentiation back to their primitive origin and then differentiation back to their primitive origin and then transform into endometrial cellstransform into endometrial cells..

This transformation into endometrial cells may be due to This transformation into endometrial cells may be due to hormonal stimuli of ovarian originhormonal stimuli of ovarian origin

33..Vascular and lymphatic spreadVascular and lymphatic spread::

Vascular and lymphatic embolization Vascular and lymphatic embolization of endometrial cells to distant organs of endometrial cells to distant organs has been demonstrated and explain has been demonstrated and explain the rare finding of endometriosis in the rare finding of endometriosis in sites outside the peritoneal cavitysites outside the peritoneal cavity..

This will explain foci in the kidneys, This will explain foci in the kidneys, joints, skin and lungjoints, skin and lung..

44..Genetic and immunological factorsGenetic and immunological factors::

It has been suggested that genetic It has been suggested that genetic and immunological factors may alter and immunological factors may alter susceptibility of a woman and allow susceptibility of a woman and allow her to develop endometriosisher to develop endometriosis..

There appear to be an increased There appear to be an increased incidence in the 1incidence in the 1stst degree relatives degree relatives

of patients with the disorderof patients with the disorder . .Also there is racial difference with Also there is racial difference with increased incidence amongst oriental increased incidence amongst oriental women and low prevalence in women and low prevalence in patients of Afro-Caribbean originpatients of Afro-Caribbean origin..

55..The role of the immune systemThe role of the immune system:: The activity of peritoneal natural killer The activity of peritoneal natural killer and T-lymphocytes is suppressed in and T-lymphocytes is suppressed in women with endometriosis , but women with endometriosis , but whether these immunologic deviations whether these immunologic deviations are the cause or the result of are the cause or the result of endometriosis is still unclearendometriosis is still unclear..

Endometriosis may occur when a Endometriosis may occur when a deficiency in cellular immunity allows deficiency in cellular immunity allows menstrual tissue to implant and grow menstrual tissue to implant and grow on the peritoneumon the peritoneum..

PathologyPathology::

The gross appearance of The gross appearance of endometriosis is quite characteristicendometriosis is quite characteristic..

The smallest and earliest implants are The smallest and earliest implants are red, petechial lesions on the red, petechial lesions on the peritoneal surfaceperitoneal surface..

With further growth, menstrual- like With further growth, menstrual- like detritus accumulates within the detritus accumulates within the lesion giving it a lesion giving it a cystic, dark brown, cystic, dark brown, dark blue, or black appearance dark blue, or black appearance (burned drum-stick appearance(burned drum-stick appearance..

Ovarian endometriosisOvarian endometriosis

The surrounding peritoneal surface The surrounding peritoneal surface becomes thickened and scarredbecomes thickened and scarred..

These powder burn implants typically These powder burn implants typically attain a size of 5-1o mm in diameterattain a size of 5-1o mm in diameter..

With progression of the diseaseWith progression of the disease , , the the number and size of the lesion increase number and size of the lesion increase and extensive adhesions developand extensive adhesions develop..

On the ovary, the cysts enlarge to several On the ovary, the cysts enlarge to several centimeters in size and are called centimeters in size and are called endometriomas or chocolate cystsendometriomas or chocolate cysts..

The most common sites of the disease areThe most common sites of the disease are::

11..TheThe oovaries varies (approximately half of the cases) which of (approximately half of the cases) which of two types two types superficialsuperficial small lesions and these lesions small lesions and these lesions with time will go deep in the ovary and coalesces with time will go deep in the ovary and coalesces together forming single big cyst(deep lesion)together forming single big cyst(deep lesion)..

22..Then the uterine cul-de-sac (Pouch of Douglas)Then the uterine cul-de-sac (Pouch of Douglas) . .

33..Uterosacral ligamentsUterosacral ligaments..

44..The posterior surface of the uterus and broad The posterior surface of the uterus and broad ligamentsligaments..The remaining pelvic peritoneumThe remaining pelvic peritoneum..

OTHER SITES AREOTHER SITES ARE::55..Implants may occur over the bowel, bladder, and Implants may occur over the bowel, bladder, and

uretersureters..rarely they may erode into underlying tissue and cause rarely they may erode into underlying tissue and cause blood in stool or urineblood in stool or urine..Or the associated adhesions may results in stricture and Or the associated adhesions may results in stricture and obstruction of these organsobstruction of these organs..

66..Implants may occur on the cervix, posterior vaginal Implants may occur on the cervix, posterior vaginal fornixfornix..

77..Also within wounds contaminated by endometrial Also within wounds contaminated by endometrial tissue e.g. scar of C/S or episiotomytissue e.g. scar of C/S or episiotomy..

88..Very rarely lesions may found in the lung, brain, and Very rarely lesions may found in the lung, brain, and kidneyskidneys..

Clinical features: Clinical findings vary greatly depending on the Clinical findings vary greatly depending on the number, size and extent of the lesionnumber, size and extent of the lesion..

The main presenting symptoms areThe main presenting symptoms are::

--InfertilityInfertility..

--Dysmenorrhoea usually congestive typeDysmenorrhoea usually congestive type..

--Dyspareunia (usually deep Dyspareunia)Dyspareunia (usually deep Dyspareunia)..

--Most patients complain of constant pelvic Most patients complain of constant pelvic pain or a low sacral backache that occur pain or a low sacral backache that occur premenstruallypremenstrually..

There may cycle abnormalities like There may cycle abnormalities like menorrhagia or polymenorrheamenorrhagia or polymenorrhea

--Lesions on or near the external surface of the Lesions on or near the external surface of the cervix, vagina, vulva urethra and rectum may cervix, vagina, vulva urethra and rectum may cause pain or bleeding with defecation, cause pain or bleeding with defecation, urination or coitus at any time in the urination or coitus at any time in the menstrual cyclemenstrual cycle

--Other symptoms are related to the site of the Other symptoms are related to the site of the lesionlesion..Lesions in the urinary tractLesions in the urinary tract cause cyclical cause cyclical dysuria and haematuriadysuria and haematuria..

--In Gastrointestinal tractIn Gastrointestinal tract cause dyschezia, cause dyschezia, cyclical rectal bleeding and obstructioncyclical rectal bleeding and obstruction..

--in the Lungin the Lung cause cyclical haemoptysis and cause cyclical haemoptysis and haemopneumothoraxhaemopneumothorax..

--In the umbilicus and surgical scarsIn the umbilicus and surgical scars : cyclical : cyclical pain and bleedingpain and bleeding..

The occurrence of abnormal The occurrence of abnormal cyclical bleeding at the time of cyclical bleeding at the time of menstruation from the rectum , menstruation from the rectum , bladder or umbilicusbladder or umbilicus is is pathognomic of the diseasepathognomic of the disease..

The physical examination classically revealsThe physical examination classically reveals::••Tender nodules in the posterior vaginal Tender nodules in the posterior vaginal

fornixfornix..••Pain upon uterine motionPain upon uterine motion..

••The uterus may be fixed and retroverted due The uterus may be fixed and retroverted due to cul-de-sac adhesionsto cul-de-sac adhesions..

••Tender adnexial masses may be felt due to Tender adnexial masses may be felt due to the presence of endometriomasthe presence of endometriomas..

••Careful inspection may reveals implants in Careful inspection may reveals implants in healed wounds especially episiotomy and healed wounds especially episiotomy and caesarian section incisions, in the vaginal caesarian section incisions, in the vaginal fornix or on the fornix or on the cervixcervix..

••Many patients are asymptomatic and Many patients are asymptomatic and have no abnormal findings on have no abnormal findings on examinationexamination..

DiagnosDiagnosisis

The diagnosis of endometriosis The diagnosis of endometriosis can be suggested by the clinical can be suggested by the clinical findings mentioned abovefindings mentioned above . .

However a However a specific diagnosis specific diagnosis requires visualization and in requires visualization and in uncertain cases, biopsy of uncertain cases, biopsy of lesions, either at laparoscopy or lesions, either at laparoscopy or laparotomylaparotomy..

LaparoscopyLaparoscopy::

Laparoscopy remain the gold standard means Laparoscopy remain the gold standard means of diagnosing this condition. Itof diagnosing this condition. It provideprovide::

11..direct visualization of endometriotic lesionsdirect visualization of endometriotic lesions..22..To take biopsy from suspected areasTo take biopsy from suspected areas..

33..Allows staging of the disease depending on Allows staging of the disease depending on the the extent of adhesionsextent of adhesions and the and the number number and and size of lesionssize of lesions..

44..Also allows concurrent therapy in the form of Also allows concurrent therapy in the form of cautery or laser treatment in selected casescautery or laser treatment in selected cases . .

--Ultrasound , CT-scan and MRI have little value Ultrasound , CT-scan and MRI have little value in the diagnosis of endometriosisin the diagnosis of endometriosis..

Staging of the diseaseStaging of the disease::

Endometriosis is classified into Endometriosis is classified into mild ,mild , moderate, sever and extensivemoderate, sever and extensive using using the the American Fertility SocietyAmerican Fertility Society’’s s scoring systemscoring system which depend on the which depend on the

11..Extent of the lesions (number and size Extent of the lesions (number and size ))..

22..Associated adhesions in the Associated adhesions in the peritoneumperitoneum..

Endometriosis and infertilityEndometriosis and infertility::

••It is estimated that 30-40% of patients with endometriosis haveIt is estimated that 30-40% of patients with endometriosis have difficulty in conceivingdifficulty in conceiving..

••In the sever disease there is usually anatomical distortion with peri-In the sever disease there is usually anatomical distortion with peri-adnexial adhesions and destruction of ovarian tissues when adnexial adhesions and destruction of ovarian tissues when endometriomas developendometriomas develop..

••But with mild disease it is still unclear why it cause infertilityBut with mild disease it is still unclear why it cause infertility.. Numerous mechanisms have been proposed, including abnormal folliculogenesis, anovulation, luteal insufficiency ,luteinized unruptured follicle syndrome, recurrent miscarriage ,decreased sperm survival, altered immunity, intraperitoneal inflammation and endometrial dysfunction .

-However, all these functional disturbances can occur in subfertile women without endometriosis,

-which suggests that finding disease during investigation

for subfertility may be coincidental.

TreatmentTreatment:: Treatment options are dictated byTreatment options are dictated by

••The patientThe patient’’s symptomss symptoms . .••Her ageHer age . .

••The stage of her diseaseThe stage of her disease..••Her desire for future fertilityHer desire for future fertility . .

The aim of the treatment areThe aim of the treatment are::••To relieve painTo relieve pain . .

•• Allows satisfactory coitusAllows satisfactory coitus. . ••Improves the patient’s fertility if possibleImproves the patient’s fertility if possible..

TreatmentTreatment modalities availablemodalities available:: Medical treatmentMedical treatment::

11..NSAIDNSAID..

22..Oral contraceptive pillsOral contraceptive pills..

33..Progestational agentsProgestational agents..

44..Danazol and GestrinoneDanazol and Gestrinone . .

55..LHRH- analogue (GnRH agonist)LHRH- analogue (GnRH agonist)..

Surgical treatmentSurgical treatment::

11..Conservative (by laparoscopy or laparotomy)Conservative (by laparoscopy or laparotomy)

22..Radical surgeryRadical surgery..

Medical treatmentMedical treatment::

11..Analgesic therapyAnalgesic therapy::

••Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drugs are potent analgesicsare potent analgesics..

••They are helpful in reducing the They are helpful in reducing the severity of dysmenorrhoeaseverity of dysmenorrhoea..

••It has no effect on the disease and itIt has no effect on the disease and it’’s s progressionprogression..

••So their use is as adjunctive treatment So their use is as adjunctive treatment onlyonly..

22..Hormonal therapyHormonal therapy::

The aim of treatment with hormonal therapy is to The aim of treatment with hormonal therapy is to interrupt the cycles of stimulation and bleeding of interrupt the cycles of stimulation and bleeding of endometriotic tissue by giving drugs that suppress endometriotic tissue by giving drugs that suppress the ovarian cycle. This can be achieved with various the ovarian cycle. This can be achieved with various agentsagents..

11..Oral contraceptive pillsOral contraceptive pills::

••This is prescribed as 1This is prescribed as 1 pill a day for 6-12 monthspill a day for 6-12 months..••The continuous exposure to combined oral The continuous exposure to combined oral

contraceptive pills results in decidual changes in the contraceptive pills results in decidual changes in the endometrial glandsendometrial glands..

••Rate of pregnancy following discontinuation of therapy Rate of pregnancy following discontinuation of therapy can be as high as 50%can be as high as 50%..The patient may have break through bleeding, weight The patient may have break through bleeding, weight gain, headache, nausea, mood changesgain, headache, nausea, mood changes..

Progestational agentsProgestational agents::

These agents cause decidualization in These agents cause decidualization in the endometriotic tissuethe endometriotic tissue..

••Oral medroxyprogesterone acetateOral medroxyprogesterone acetate can be prescribed as a 10-30mg dailycan be prescribed as a 10-30mg daily..

••Depot medroxyprogesterone acetateDepot medroxyprogesterone acetate 150mg i.m can be given as a single 150mg i.m can be given as a single dose every 3 monthsdose every 3 months..

••Side effectsSide effects::••Irritability, depression, breakthrough Irritability, depression, breakthrough

bleeding, and bloatingbleeding, and bloating..

DanazolDanazol:: ••Danazol is a weak androgenDanazol is a weak androgen..

••Danazol acts via several mechanisms to treat endometriosis Danazol acts via several mechanisms to treat endometriosis by by ofof||causing amenorrhea and atrophycausing amenorrhea and atrophy

The dosage of Danazol is The dosage of Danazol is 400-800mg/day400-800mg/day in divided doses for in divided doses for 6months6months . .Side effectsSide effects: :

••AcneAcne..••Oily skinOily skin..

••Deepening of the voiceDeepening of the voice..••Weight gainWeight gain..

••EdemaEdema..••Adverse plasma lipoprotein changesAdverse plasma lipoprotein changes..

••Most changes are reversible upon cessation of therapyMost changes are reversible upon cessation of therapy..GestrinoneGestrinone inhibit LH &FSH secretion in a dose of 2.5mg inhibit LH &FSH secretion in a dose of 2.5mg twice weekly with similar side effects of Danazoltwice weekly with similar side effects of Danazol..

Gonadotropin- releasing hormone Gonadotropin- releasing hormone agonists (GnRH agonist )agonists (GnRH agonist )..

**These agents are analogues of GnRHThese agents are analogues of GnRH..**When given continuously cause When given continuously cause

suppression of gonadotropin secretionsuppression of gonadotropin secretion..**So suppress ovarian cycle and So suppress ovarian cycle and

endometrial implantsendometrial implants..GnRH agonists can be administeredGnRH agonists can be administered

•• intramuscularlyintramuscularly e.g. leuprolide acetate e.g. leuprolide acetate 3.75mg once a month3.75mg once a month..

••IntranasalyIntranasaly as nafarelin 200mg twice as nafarelin 200mg twice dailydaily..

••subcutaneously subcutaneously as goserlin 3.75 mg as goserlin 3.75 mg once a monthonce a month..

These agents are used for 6 months because These agents are used for 6 months because of their side effects related to the hypo-of their side effects related to the hypo-estrogenic state includingestrogenic state including::

••Lose of bone mineral density (the most Lose of bone mineral density (the most important one causing osteoporosis)important one causing osteoporosis)..

••Vasomotor symptomsVasomotor symptoms..

••Vaginal drynessVaginal dryness..

••Mood changesMood changes..

Now a days they start to add low dose Now a days they start to add low dose estrogen e.g.0.625 mg of conjugated equine estrogen e.g.0.625 mg of conjugated equine estrogen to relieve the side effects of these estrogen to relieve the side effects of these drugs especially the bone losedrugs especially the bone lose..

Surgical treatmentSurgical treatment::

11..Conservative surgical treatmentConservative surgical treatment:: This is indicated for women with This is indicated for women with infertility, infertility, who have sever disease and symptoms with who have sever disease and symptoms with adhesionsadhesions..By surgery we shouldBy surgery we should : :

••excise or destroy all endometriotic tissuesexcise or destroy all endometriotic tissues ••Remove all adhesions (adhesolysis)Remove all adhesions (adhesolysis)..

••Restore pelvic anatomy to the best possible Restore pelvic anatomy to the best possible conditioncondition..

••Tubal surgeryTubal surgery..••Pre-sacral neurectomy or Uterosacral Pre-sacral neurectomy or Uterosacral

ligaments ablation to relieve painligaments ablation to relieve pain..••Uterine suspension also done if requiredUterine suspension also done if required..

..

••All these procedures can be performed All these procedures can be performed by by laparoscopy or laparotomylaparoscopy or laparotomy..

•• For women with infertility who For women with infertility who failed all other therapy can failed all other therapy can undergoes assisted reproduction undergoes assisted reproduction (in vitro fertilization)(in vitro fertilization)..

Definitive surgeryDefinitive surgery:: For patient with For patient with severe disease or symptoms, severe disease or symptoms, who does not desire further pregnancywho does not desire further pregnancy..

This includes This includes total abdominal hysterectomy total abdominal hysterectomy and bilateral salpingo-oophorectomy with and bilateral salpingo-oophorectomy with excision of the remaining adhesions or excision of the remaining adhesions or implantsimplants..

Post-operative medical therapy may be Post-operative medical therapy may be indicated in some patients to get rid of all indicated in some patients to get rid of all remaining implantsremaining implants..

Women who undergo definitive surgery can be Women who undergo definitive surgery can be given hormone replacement therapy with out given hormone replacement therapy with out reactivation of endometriotic tissuesreactivation of endometriotic tissues..

AdenomyosisAdenomyosis::Means the presence ofMeans the presence of endometrial glands and endometrial glands and stroma deep within the myometriumstroma deep within the myometrium..

--It has a different etiology than endometriosisIt has a different etiology than endometriosis..--The exact etiology is unknown but it has been The exact etiology is unknown but it has been

suggested to be related to suggested to be related to weakness of the weakness of the myometrial smooth muscle from repeated myometrial smooth muscle from repeated pregnancies, or trauma induced by surgerypregnancies, or trauma induced by surgery..The incidence of this condition is more inThe incidence of this condition is more in::

11..Multiparous women in their late thirties or early Multiparous women in their late thirties or early forties of ageforties of age..

22..Women who has previous curettage or induced Women who has previous curettage or induced abortionabortion..

33..More common in women having endometrial More common in women having endometrial hyperplasia and fibroidshyperplasia and fibroids . .

clinically the patientclinically the patient presented with increasingly presented with increasingly severe secondary dysmenorrhoea and menorrhagiasevere secondary dysmenorrhoea and menorrhagia..The uterus is bulky and tender particularly if The uterus is bulky and tender particularly if examined perimenstruallyexamined perimenstrually..

DiagnosisDiagnosis:: Clinical features are non specificClinical features are non specific..

Transvaginal ultrasound may show alteration of Transvaginal ultrasound may show alteration of echogenicity within the myometrium from the echogenicity within the myometrium from the localized distended endometrial glands. some times localized distended endometrial glands. some times the appearance may resemble uterine fibroidthe appearance may resemble uterine fibroid . .

MRI may be more specific than ultrasound in the MRI may be more specific than ultrasound in the diagnosisdiagnosis..

However specific diagnosis for suspected cases is However specific diagnosis for suspected cases is only obtained only obtained by pathological examination of the by pathological examination of the hysterectomy specimen performed for symptomatic hysterectomy specimen performed for symptomatic reasonsreasons..

TreatmentTreatment::••Drugs that induce amenorrhoea are Drugs that induce amenorrhoea are

helpful since they relieve pain and helpful since they relieve pain and excessive bleeding (Danazol, Gestrinone excessive bleeding (Danazol, Gestrinone and GnRH agonist can be used)and GnRH agonist can be used)..

••However on stopping the treatment However on stopping the treatment symptoms return rapidly in the majority symptoms return rapidly in the majority of patientsof patients..

So hysterectomy is the only definitive So hysterectomy is the only definitive treatment availabletreatment available..

Thank youThank you