15: Endometriosis and adenomyosis Flashcards
endometriosis most likely implants where?
ovary or pelvic peritoneum
other: posterior uterus and broad ligaments, the uterosacral ligaments, fallopian tubes, colon, and appendix
-rare: breast, lung, and brain.
10% to 15% of women of reproductive age
The hallmark of endometriosis
other symptoms?
cyclic pelvic pain, which is at its worst 1 to 2 days before menses and subsides at the onset of flow or shortly thereafter
-dysmenorrhea, dyspareunia, abnormal bleeding, bowel and bladder symptoms, and subfertility
does the severity of symptoms correlate with the extent of disease in endometriosis?
may not correlate with extent of disease (dysmenorrhea, dyspareunia, abnormal bleeding, and infertility)
Complications of endometriosis
intra-abdominal inflammation and bleeding that can cause scarring, pain, and adhesion formation, which can lead to infertility and chronic pelvic pain
the only way to definitively diagnose endometriosis
Direct visualization with diagnostic laparoscopy or laparotomy (preferably with histologic confirmation with biopsy)
medical management of endometriosis
NSAIDs, OCPs, progestins, danazol, GnRH agonists
-reduce pain, but these methods are used mainly as temporizing agents.
sx management of endometriosis
conservative therapy to ablate implants and lyse adhesions while preserving the uterus and ovaries.
- follow immediately by medical therapy to delay the recurrence of endometrial implants and pain
- treat definitively with total hysterectomy (often with bilateral salpingo-oophorectomy) lysis of adhesions, and removal of endometriosis lesions
adenomyosis
extension of endometrial tissue into the myometrium making the uterus diffusely enlarged, boggy, and globular.
- hypertrophy and hyperplasia of the myometrium adjacent to the ectopic endometrial tissue
- most extensive in the fundus and posterior uterine wall
- theory: high levels of estrogen stimulate hyperplasia of the basalis layer of the endometrium.
adenomyosis s/s
-increasing secondary dysmenorrhea and/or menorrhagia; 30% of patients are asymptomatic.
adenomyosis dx
may be suggested on pelvic US
*MRI can best distinguish between adenomyosis and fibroids.
if 45 and older with abnormal uterine bleeding should also have an EMB to rule out hyperplasia and cancer
minimal symptoms of adenomyosis may be treated with
analgesics, NSAIDs, OCPs, or progestins, although adenomyosis is less responsive to hormonal management than endometriosis.
the most effective temporary means of treating the symptoms of adenomyosis?
definitive means?
levonorgestrel-containing IUD
hysterectomy
Halban theory of endometriosis
proposes endometrial tissue is transported via the lymphatic system to various sites in the pelvis, where it grows ectopically.
Meyer theory of endometriosis
multipotential cells in peritoneal tissue undergo metaplastic transformation into functional endometrial tissue.
Sampson theory of endometriosis
suggests that endometrial tissue is transported through the fallopian tubes during retrograde menstruation, resulting in intra-abdominal pelvic implants.
A prevailing theory is that women who develop endometriosis may have
an altered immune system that is less likely to recognize and attack ectopic endometrial implants.
Approximately 20% of women with chronic pelvic pain and 30% to 40% of women with infertility have ?
endometriosis
risks factors for endometriosis
Nulliparity, early menarche, prolonged menses, and müllerian anomalies, first-degree relatives (mother or sisters) with endometriosis, increased rates of some autoimmune inflammatory disorders
how endometriosis may cause infertility
moderate to severe endometriosis can cause dense adhesions, which can distort the pelvic architecture, interfere with tubal mobility, impair oocyte release, and cause tubal obstruction
PE findings in endometriosis
may be subtle
-uterosacral nodularity and tenderness on rectovaginal examination or a fixed retroverted uterus. Pain with movement of the uterus can often be seen. When the ovary is involved, a tender, fixed adnexal mass may be palpable on bimanual examination or viewed on pelvic US
endometriosis findings on laparoscopy
implants: rust-colored to dark brown powder burns or raised, blue-colored mulberry or raspberry lesions surrounded by reactive fibrosis that can lead to dense adhesions in extensive disease.
ovary: large cystic collections of endometriosis filled with thick, dark, old blood and debris known as endometriomas or chocolate cysts
- peritoneal biopsy for histo conformation
endometriosis classification based on
location, depth, and diameter of lesions and density of adhesions.
ddx endometriosis
other chronic processes that result in recurring pelvic pain or an ovarian mass: PID, adenomyosis, IBS, interstitial cystitis, pelvic adhesions, functional ovarian cysts, ectopic pregnancy, and ovarian neoplasms
goal of medical management of endometriosis
suppression and atrophy of the endometrial tissue
- induce a state of “ pseudopregnancy” by suppressing both ovulation and menstruation and by decidualizing the endometrial implants, thereby alleviating the cyclic pelvic pain and dysmenorrhea
- or “pseudomenopause” (danazol and GnRH agonists)
- or blocking conversion to estrogens (aromatase inhibitors: anastrozole, letrozole)
- temporary, does not help fertility
add-back therapy for endometriosis
add a small amount of progestin with or without estrogen to the GnRH agonist to minimize the symptoms caused by estrogen deficiency such as hot flashes and bone density loss
adenomyoma
A well-circumscribed collection of endometrial tissue within the uterine wall. They may also contain smooth muscle cells and are not encapsulated. Adenomyomas can also prolapse into the endometrial cavity similar to a classic endometrial polyp.
any patient age 45 or older with change in menstrual quantity or pattern should have ?
a TSH, pelvic ultrasound, and an endometrial biopsy to rule out other causes of abnormal uterine bleeding
ddx adenomyosis
uterine enlargement, menorrhagia, and/or dysmenorrhea including uterine fibroids, polyps, menstrual disorders, endometrial hyperplasia, endometrial cancer, pregnancy, and adnexal masses.
