15: Endometriosis and adenomyosis

Question 1

endometriosis most likely implants where?

Answer 1

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

Question 2

The hallmark of endometriosis

other symptoms?

Answer 2

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

Question 3

does the severity of symptoms correlate with the extent of disease in endometriosis?

Answer 3

may not correlate with extent of disease (dysmenorrhea, dyspareunia, abnormal bleeding, and infertility)

Question 4

Complications of endometriosis

Answer 4

intra-abdominal inflammation and bleeding that can cause scarring, pain, and adhesion formation, which can lead to infertility and chronic pelvic pain

Question 5

the only way to definitively diagnose endometriosis

Answer 5

Direct visualization with diagnostic laparoscopy or laparotomy (preferably with histologic confirmation with biopsy)

Question 6

medical management of endometriosis

Answer 6

NSAIDs, OCPs, progestins, danazol, GnRH agonists

-reduce pain, but these methods are used mainly as temporizing agents.

Question 7

sx management of endometriosis

Answer 7

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

Question 8

adenomyosis

Answer 8

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.

Question 9

adenomyosis s/s

Answer 9

-increasing secondary dysmenorrhea and/or menorrhagia; 30% of patients are asymptomatic.

Question 10

adenomyosis dx

Answer 10

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

Question 11

minimal symptoms of adenomyosis may be treated with

Answer 11

analgesics, NSAIDs, OCPs, or progestins, although adenomyosis is less responsive to hormonal management than endometriosis.

Question 12

the most effective temporary means of treating the symptoms of adenomyosis?
definitive means?

Answer 12

levonorgestrel-containing IUD

hysterectomy

Question 13

Halban theory of endometriosis

Answer 13

proposes endometrial tissue is transported via the lymphatic system to various sites in the pelvis, where it grows ectopically.

Question 14

Meyer theory of endometriosis

Answer 14

multipotential cells in peritoneal tissue undergo metaplastic transformation into functional endometrial tissue.

Question 15

Sampson theory of endometriosis

Answer 15

suggests that endometrial tissue is transported through the fallopian tubes during retrograde menstruation, resulting in intra-abdominal pelvic implants.

Question 16

A prevailing theory is that women who develop endometriosis may have

Answer 16

an altered immune system that is less likely to recognize and attack ectopic endometrial implants.

Question 17

Approximately 20% of women with chronic pelvic pain and 30% to 40% of women with infertility have ?

Answer 17

endometriosis

Question 18

risks factors for endometriosis

Answer 18

Nulliparity, early menarche, prolonged menses, and müllerian anomalies, first-degree relatives (mother or sisters) with endometriosis, increased rates of some autoimmune inflammatory disorders

Question 19

how endometriosis may cause infertility

Answer 19

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

Question 20

PE findings in endometriosis

Answer 20

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

Question 21

endometriosis findings on laparoscopy

Answer 21

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

Question 22

endometriosis classification based on

Answer 22

location, depth, and diameter of lesions and density of adhesions.

Question 23

ddx endometriosis

Answer 23

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

Question 24

goal of medical management of endometriosis

Answer 24

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

Question 25

add-back therapy for endometriosis

Answer 25

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

Question 26

adenomyoma

Answer 26

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.

Question 27

any patient age 45 or older with change in menstrual quantity or pattern should have ?

Answer 27

a TSH, pelvic ultrasound, and an endometrial biopsy to rule out other causes of abnormal uterine bleeding

Question 28

ddx adenomyosis

Answer 28

uterine enlargement, menorrhagia, and/or dysmenorrhea including uterine fibroids, polyps, menstrual disorders, endometrial hyperplasia, endometrial cancer, pregnancy, and adnexal masses.