Adenomyosis and Endometriosis

Question 1

The fundamental difference between adenomyosis and endometriosis

Answer 1

• Adenomyosis: Endometrial tissue in the myometrium
• Endometriosis: Endometrial tissue outside of the uterus entirely

Question 2

Locations of endometriosis

Answer 2

• Pelvic (most common):
  
  • Ovaries
  • Fallopian tubes
  • Rectouterine pouch
  • Bladder
  • Cervix
• Peritoneum
• Extra-pelvic sites (uncommon):
  
  • Lungs
  • Diaphragm

Question 3

Complications of endometrial implants in endometriosis

Answer 3

• Increased production of inflammatory and pain mediators
• Nerve dysfunction
• Altered anatomy (pelvic adhesions, ovarian fibrosis)
  
  • Infertility secondary to altered anatomy

Question 4

Symptoms of endometriosis

Answer 4

• Chronic pelvic pain that worsens before onset of menses
• Dysmenorrhea*
• Pre- or post- menstrual bleeding
• Dyspareunia*
• Infertility
• Dyschezia
• Sometimes asymptomatic

Question 5

Diagnosing endometriosis

Answer 5

1. Transvaginal ultrasound (best initial test)
   
   • Uterus generally not enlarged (no fibroids)
   • Evidence of ovarian cysts (chocolate cysts: cyst-like ovarian structure that contains blood, fluid, and menstrual debris)
   • Nodules in bladder or rectovaginal setpum
2. Laporoscopy (confirmatory test)
   
   • Shows endometriotic implants and adhesions

Question 6

Retrograde flow theory of endometriosis

Answer 6

Suggests that a small amount of endometrial tissue undergoes retrograde flow during menses, going up the fallopian tubes and potentially into the ovaries or peritoneal cavity, and ultimately implants at these locations

Question 7

___% of reproductive-age women with chronic pelvic pain have endometriosis

Answer 7

~75% of reproductive-age women with chronic pelvic pain have endometriosis

Question 8

Vascular and lymphatic dissemination theory of endometriosis

Answer 8

Theory that endometrial cells make it into the bloodstream or lymphatics during menses and travel from here to distant sites, implanting in locations like the lung or kidney

Question 9

Coelomic metaplasia theory of endometriosis

Answer 9

Suggests that peritoneal stem cells differentiate into endometrial tissue inappropriately at distant sites, independent of the uterus.

This theory explains the presence of endometriosis in girls who have not yet undergone menarche

Question 10

Endometriomas often appear brown or rusty. Why?

Answer 10

They are often hemosiderin-laden, giving them some pigmentation

Question 11

Visualizing endometriosis during surgery

Answer 11

• Can take on a few appearances:
  
  • White lesions with rusty hemosiderin stains
  • Dark blue or red domes
  • Black, powder-burn-like lesions

Question 12

Classic signs of endometriosis on physical exam

Answer 12

• Fixed, non-mobile uterus (due to scarring)
• Uterosacral nodularity (palpating endometriomas)
• Ovarian nodularity (palpating endometriomas)

Question 13

Diagnosis of endometriosis

Answer 13

An operative diagnosis that can only be made during surgery

Can be made visually and confirmed by biopsy

Question 14

Treating endometriosis

Answer 14

• Goal: Induce atrophy of ectopic endometrial tissue
• 1st line: OCP or progesterone therapy
• 2nd line: Leuprelide (temporizing measure only), danazol (LH/FSH suppressor)
• Surgical:
  
  • Conservative: Excision, cauterization, ablation of visible lesions, lysis of adhesions
  • Exterpative: Hysterectomy +/- BSO

Question 15

Women with unicornate uteri are at high risk for endometriosis. Why is this?

Answer 15

Because they often have retrograde menses, enabling endometrial tissue to access the peritoneal cavity and implant

Question 16

Endometriomas

Answer 16

Aka “chocolate cysts”

Enlarged, white ovaries with a large amount of endometriosis. Often covered with hemosiderin-laden material which appears brown or rusty on laporoscopy.

Question 17

Endometriosis on transvaginal ultrasound

Answer 17

Here the “reticular pattern” is due to the presence of blood

Question 18

__ is often elevated and can be a biomarker for endometriosis, but it is rarely used as it has a poor sensitivity for mild disease.

Answer 18

CA-125 is often elevated and can be a biomarker for endometriosis, but it is rarely used as it has a poor sensitivity for mild disease.

Question 19

Typical course of someone with endometriosis

Answer 19

Empirically tried on progestin or OCP. If this works, the diagnosis is presumed correct, but is not definitive.

If this fails, then exploratory laporotomy or laporoscopy is indicated and official diagnosis can be made.

Question 20

Normal uterus size

Answer 20

~8 cm in a woman of reproductive age

~4 cm in a post-menopausal woman

Question 21

Why don’t we use CT for looking inside the pelvis?

Answer 21

Too much bone!

Ultrasound is actually better resolution. MRI is the best, but it is expensive and often not necessary.

Question 22

Dysmenorrhea that does not respond to NSAIDs

Answer 22

Endometriosis should be suspected

Question 23

Presentation of ruptured endometrioma

Answer 23

Sudden, severe abdominal pain

Ddx: ectopic pregnancy, PID, adnexal torsion, rupture of lutein cyst (GTD), ovarian neoplasm

Question 24

All of the cases where CA-125 is elevated

Answer 24

GYN: Endometriosis, fibroids, PID, ovarian epithelial cancers

Non-GYN: Cirrhosis, pancreatic cancer, lung cancer

Question 25

Oral medroxyprogesterone in endometriosis

Answer 25

Form of endometriosis hormonal therapy that can be used as an ovarian stimulant instead of as a contraceptive, for those with endometriosis who wish to become pregnant soon.

Question 26

Surgically treated endometriosis and fibromas both tend to. . .

Answer 26

. . . recur.

For endometriosis, ~1/3 will recur within 5 years

For fibroids, ~1/2 will recur

Question 27

Add-back adjuvant therapy w/ leuprolide

Answer 27

Low-dose OCP, medroxyprogesterone, or norethindione given along with leuprolide to decrease menopausal symptoms.

Does not affect the drug’s control of pelvic pain in patients with endometriosis.

Question 29

Cervical stenosis as a risk factor for endometriosis

Answer 29

Cervical stenosis, which may result from LEEP or cone biopsy of the cervix, creates a temporary plug that may induce retrograde menstrual flow, resulting in endometriosis.