Gynecology - Endometriosis and adenomyosis Flashcards
What is endometriosis?
The presence of endometrial glands and stroma outside the normal location, excluding adenomyosis. Hormonally dependent disease.
What is the most common presenting sx of endometriosis?
Chronic pelvic pain, which may be localized or radiate to the upper back or leg.
Pain sx: may be cyclical or chronic. cause is unclear but likely to be related to icnreased cytokines and prostaglandins.
- Dysmenorrhea - pain precedes menses by 24-48h, less responsive to NSAIDS and COCs
- Dyspareunia
- Dysuria
- Defecatory pain
- Infertility/subfertility
- Intestinal, urethral obstruction.
Risk factors for endometriosis?
- Familial clustering
- Increased incidence in first-degree relatives
- Women w/severe endometriosis are far more likely to have an affected first-degree relative. - Genetic mutations
- No specific gene, but a risk factor - Anatomic defect
- Increased incidence in women w/outflow tract obstruction - Environmental factors:
- TCDD/dioxins
- Caffeine
- Alcohol use
Physical examination of endometriosis
Speculum exam: usually normal, occasionally blue or powder-burn red lesions which will easily bleed. Bimanual examination: varies greatly - Uterosacral nodularity and tenderness - Fixed retroverted uterus - Enlarged cystic adnexal mass - Fixed, firm posterior cul-de sac.
What is the mainstay in evaluating sx assoc. w endometriosis?
Transvaginal sonography. CT, MRI are used in selected cases.
What is the gold standard in diagnosing endometriosis?
Diagnostic laporascopy, however, in most cases, medical mx will be attempted first.
Medical management of endometriosis:
- NSAIDS = first line
- COC
- Progestines
- Androgens (Danazol gestrinone)
- GnRH agonists (Leuprolide, goserelin, nafarelin)
- Aromatase inhibitors: second-line tx
Surgical management of endometriosis?
- Lesion ablation w/adhesiolysis
- Endometrioma resection
- Presacral neurectomy
- Hysterectomy w/BSO is the most definite surgical management and may be considered in women who are done bearing children.
What is adenomyosis?
Uterine enlargement caused by ectopic rests of endometrial tissue in the myometrium, may be diffuse or focal.
Shared features of endometriosis and adenomyosis
- Both characterized by ectopic endometrial tissue
- Both cause pelvic pain
- Both are hormonally sensitive
- Both cause pain and are related to elevated PG levels
- Both significantly remit after menopause.
=> Unlike endometriosis, adenomyosis tends to present in older women (but pre-menopausal) + fertility issues are not as common w adenomyosis as with endometriosis.
Cause of adenomyosis?
Most likely due to direct invasion of the endometrium into the myometrial layer, resulting in foci of endometrium within the myometrium. Increased vascularization of endometrium near the adenomyotic foci; ectopic estrogen production -> increased bleeding (menorrhagia).
Risk factors of adenomyosis
- Age > 40-50
- Parity/parous women
- Prior uterine surgery
- Other possible RFs: smoking, antidepressants, tamoxifen.
The most common presenting symptom of adenomyosis are
Abnormal uterine bleeding and secondary dysmenorrhea, dyspareunia. Severity correlates w/number of foci and extent of invasion.
What can you see on physical examination?
Enlarged tender uterus - diffusely enlarged and boggy in adenomyosis, whereas leiomyomas will elicit a “lumpy, bumpy” texture.
What is the best initial test in suspected adenomyosis?
Transvaginal sonography. MRI is more accurate and commonly used to differentiate it from leiomyomas.
