Adenomyosis and Endometriosis Flashcards
The fundamental difference between adenomyosis and endometriosis
- Adenomyosis: Endometrial tissue in the myometrium
- Endometriosis: Endometrial tissue outside of the uterus entirely
Locations of endometriosis
-
Pelvic (most common):
- Ovaries
- Fallopian tubes
- Rectouterine pouch
- Bladder
- Cervix
- Peritoneum
-
Extra-pelvic sites (uncommon):
- Lungs
- Diaphragm
Complications of endometrial implants in endometriosis
- Increased production of inflammatory and pain mediators
- Nerve dysfunction
-
Altered anatomy (pelvic adhesions, ovarian fibrosis)
- Infertility secondary to altered anatomy
Symptoms of endometriosis
- Chronic pelvic pain that worsens before onset of menses
- Dysmenorrhea*
- Pre- or post- menstrual bleeding
- Dyspareunia*
- Infertility
- Dyschezia
- Sometimes asymptomatic
Diagnosing endometriosis
-
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
-
Laporoscopy (confirmatory test)
- Shows endometriotic implants and adhesions
Retrograde flow theory of endometriosis
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
___% of reproductive-age women with chronic pelvic pain have endometriosis
~75% of reproductive-age women with chronic pelvic pain have endometriosis
Vascular and lymphatic dissemination theory of endometriosis
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
Coelomic metaplasia theory of endometriosis
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
Endometriomas often appear brown or rusty. Why?
They are often hemosiderin-laden, giving them some pigmentation
Visualizing endometriosis during surgery
- Can take on a few appearances:
- White lesions with rusty hemosiderin stains
- Dark blue or red domes
- Black, powder-burn-like lesions
Classic signs of endometriosis on physical exam
- Fixed, non-mobile uterus (due to scarring)
- Uterosacral nodularity (palpating endometriomas)
- Ovarian nodularity (palpating endometriomas)
Diagnosis of endometriosis
An operative diagnosis that can only be made during surgery
Can be made visually and confirmed by biopsy
Treating endometriosis
- 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
Women with unicornate uteri are at high risk for endometriosis. Why is this?
Because they often have retrograde menses, enabling endometrial tissue to access the peritoneal cavity and implant
Endometriomas
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.
Endometriosis on transvaginal ultrasound
Here the “reticular pattern” is due to the presence of blood
__ is often elevated and can be a biomarker for endometriosis, but it is rarely used as it has a poor sensitivity for mild disease.
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.
Typical course of someone with endometriosis
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.
Normal uterus size
~8 cm in a woman of reproductive age
~4 cm in a post-menopausal woman
Why don’t we use CT for looking inside the pelvis?
Too much bone!
Ultrasound is actually better resolution. MRI is the best, but it is expensive and often not necessary.
Dysmenorrhea that does not respond to NSAIDs
Endometriosis should be suspected
Presentation of ruptured endometrioma
Sudden, severe abdominal pain
Ddx: ectopic pregnancy, PID, adnexal torsion, rupture of lutein cyst (GTD), ovarian neoplasm
All of the cases where CA-125 is elevated
GYN: Endometriosis, fibroids, PID, ovarian epithelial cancers
Non-GYN: Cirrhosis, pancreatic cancer, lung cancer
Oral medroxyprogesterone in endometriosis
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.
Surgically treated endometriosis and fibromas both tend to. . .
. . . recur.
For endometriosis, ~1/3 will recur within 5 years
For fibroids, ~1/2 will recur
Add-back adjuvant therapy w/ leuprolide
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.
Cervical stenosis as a risk factor for endometriosis
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.
