OB-GYN: Endometriosis and Adenomyosis

What is the classic triad of symptoms for endometriosis?

1. Dysmenorrhea ** (painful periods) 2. Dyspareunia ** (pain with sex) 3. Dyschezia ** (pain with bowel movements) •Also, Infertility

Endometriosis Conclusions 1. Endometriosis is a benign disease that spreads like _______. 2. It is a major factor causing what two symptoms? 3. There are five theories to explain its ___________. 4. It most commonly involves what two areas? 5. It has a classic triad of symptoms. 6. __________ is essential for future reference and treatment. 7. Management consists of medical or surgical depending on the patient's age, extent of disease and desire for future fertility.

1. Endometriosis is a benign disease that spreads like cancer. 2. It is a major factor causing pelvic pain and infertility. 3. There are five theories to explain its pathogenesis. 4. It most commonly involves the ovaries and also in the uterosacral ligaments 5. It has a classic triad of symptoms. 6. Staging is essential for future reference and treatment. 7. Management consists of medical or surgical depending on the patient's age, extent of disease and desire for future fertility.

•How do you tell the difference between primary dysmenorrhea and endometriosis pain?

1. Primary dysmenorrhea→ gets better with NSAIDs, prescription strength NSAIDs or low dose birth control 2. If these things don't work and the pain is still there you should think of endometriosis

What are the Five Theories of Development of endometriosis?

1. Retrograde Menstruation → main theory 2. Mullerian (Coelomic) Metaplasia 3. Lymphatic and Vascular Transport 4. Immunologic Defect 5. Genetic Predisposition

Staging of endometriosis: 1. The stage (amount of disease) often has a reverse correlation to the amount of ______. Severity of _____ more linked to depth of infiltration of underlying tissue. 2. The stage has a direct correlation to the severity of ______.

1. The stage (amount of disease) often has a reverse correlation to the amount of pain. Severity of pain more linked to depth of infiltration of underlying tissue. 2. The stage has a direct correlation to the severity of infertility.

Incidence of Endometriosis 1. Usually diagnosed in the ______ decade of life. (however, it can be diagnosed in anybody!); it is usually diagnosed during the _________ years -In general you don't form endometriosis before _______ but it can happen 2. Usually regresses after _______however, 5% of women are diagnosed after _______. -In general it regresses do to the lack of estrogen and progesterone 3. Quite often associated with genital outflow tract ___________ in adolescents. -E.g. imperforate hymen; vagina fills up with menstrual blood and it must go back out through the tubes because it can't come out through the vagina

1. Usually diagnosed in the third decade of life. (however, it can be diagnosed in anybody!); it is usually diagnosed during the reproductive years -In general you don't form endometriosis before puberty but it can happen 2. Usually regresses after menopause however, 5% of women are diagnosed after menopause. -In general it regresses after menopause do to the lack of estrogen and progesterone 3. Quite often associated with genital outflow tract obstructions in adolescents. -E.g. imperforate hymen; vagina fills up with menstrual blood and it must go back out through the tubes because it can't come out through the vagina

What is the only real cure for adenomyosis?

A hysterectomy

Endometriosis Many large endometriomas is associated with what kind of symptoms?

Asymptomatic patient

What is the most common theory of endometriosis development?

Retrograde Menstruation

Which theory of Development of endometriosis? •Endometrial implants are shed through the tubes at menstruation, implant and grow in the pelvis. •Supported by observing retrograde flow of blood at laparoscopy. •Endometrial fragments from menstrual flow can grow in tissue culture and following injection under abdominal skin. •Increased likelihood in cervical stenosis or vaginal atresia/imperforate hymen.

Retrograde Menstruation

Endometriosis Minimal disease is associated with what kind of symptoms?

Severe pain

•Very Important!!!! •Allows you to quantify the severity. (Gives a standardized diagnosis). •Guides your treatment. (Medical vs. conservative surgery or aggressive surgery). •If you or somebody else has to "go in" a second time, you will know if and how well your previous treatment has worked. This refers to what part of an endometriosis dx?

Staging

A 44 year-old female presents to the office with progressive menorrhagia. Ultrasound reveals no evidence of uterine fibroids. She has undergone previous treatments including NSAID's, oral contraceptives, D&C/Hysteroscopy. None of these has resulted in an improved bleeding pattern. Dx?

adenomyosis

•Gross appearance consists of diffuse enlargement, thickened myometrium with glandular irregularities. •Histologically, may consist of superficial extension of endometrium into the myometrium up to extension throughout the myometrial thickness. Dx?

adenomyosis

•Menorrhagia: heavy bleeding -Increased surface area of endometrial cavity -Can interfere with the normal contractility of the uterine muscle leading to increased bleeding •Severe dysmenorrhea -But they don't tend to get the pain with sex or bowel movements •Many patients are asymptomatic Dx?

adenomyosis

•Uterus is symmetrically enlarged. •Usually soft and boggy but, it may be asymmetrical and firm. Thus, making it hard to distinguish from a fibroid uterus. (like an over-ripe fruit feeling) Dx?

adenomyosis

The extension of endometrial glands and stroma into the uterine musculature.

adenomyosis •Rather than being outside of the uterus it is growing from the endometrium down into the myometrium

Cyclic hormones do what to the growth of endometriosis?

causes growth

A 29 year-old female presents to the office with pelvic pain that was initially most prominent during the premenstrual phase of her cycle. The pain has become progressively worse and now involves most of the month. The pain has not been relieved with the use of OTC NSAID's, Rx NSAID's or oral contraceptives Dx?

endometriosis

Which theory of Development of endometriosis? •Endometrial tissue is taken up into the lymphatics and vascular systems draining the uterus and transported to the various sites where they grow. •This helps to explain endometriosis of the lung, nose, spinal cord, forearm and thigh. •This may be the cause of ovarian endometriosis.

lymphatic and vascular spread

Continuous Hormones do what to the growth of endometriosis?

reverse the growth

Adenomyosis Conclusions •Adenomyosis is usually seen in 30 and 40 year olds. •Symptoms include _______and ________. •Definitive treatment is ___________

•Adenomyosis is usually seen in 30 and 40 year olds. •Symptoms include menorrhagia and dysmenorrhea. •Definitive treatment is a hysterectomy

A patient with adenomyosis tends to present with what symptoms?

•Tend to have regular periods, but excessive in amount. Don't usually have pain or infertility •They present with persistent, heavy periods

What is the mode of definitive diagnosis of endometriosis?

•The classic way is "Laparoscopy": Visual inspection by an experienced surgeon. •Histologic findings (biopsy): Can be used in questionable cases→ biopsy will show hemosiderin laden macrophages

-A cyst that forms beneath the surface of the ovary filled with chocolate-colored molasses fluid -Usually endometrial glands and stroma are present in the cyst wall -Can be adherent to the broad ligament, fallopian tube or pelvic sidewall -Can rupture and cause rapid spread of the condition -Markedly increases the staging of the endometriosis What is this description referring to?

Endometrioma

•A benign but progressive condition in which endometrial-like glands and stroma are present outside the uterus. •They are "ectopic".

Endometriosis

•Tender fixed adnexal mass on bimanual exam. •Frequently find a retroverted uterus in these women. •Sharp, firm, very tender "barb" felt on utero-sacral ligaments. "Nodular utero-sacral ligaments". Dx?

Endometriosis

•LAPAROSCOPIC FINDINGS 1. Isolated implants -Pigmented: looks like a volcano; raised around the edges and it is colored in the middle (could be brown, pink, red etc.) -Non-pigmented: volcanic appearance with white in the middle -Cryptic: there is so much inflammation that the tissue around the endometriotic implant has swollen up around the implant, all you see is a hole 2. Adnexal mass -Ovarian endometrioma -Encapsulating Adhesions: inflammatory response on the tissue can cause adhesions 3. Cul-de-sac obliteration: area behind the uterus is gone because everything is stuck, lots of adhesions Dx?

Endometriosis?

Which theory of Development of endometriosis? •Studies show a familial predisposition. Monozygotic twins have a marked concordance for endometriosis. •There is a ten-fold increase in 1st degree relatives of affected women. •1/10 women with severe endometriosis will have a sister or mother with clinical manifestations of the disease.

Genetic predisposition

What is the major cardinal feature of endometriosis seen on histology?

Hemosiderin-laden macrophages

Which theory of Development of endometriosis? •Specific defect in local cell- mediated immunity in women with endometriosis. •Studies show higher titers of antibodies to endometrial antigens in these women. •Many women have reflux seeding of menstrual debris into the peritoneal cavity and do not develop endometriosis.

Immunologic defect → tissues have a defect that allow it to happen

What are the most common areas of occurrence of endometriosis?

MOST COMMON is on the OVARIES Also the uterosacral ligament

Which theory of Development of endometriosis? •The mullerian ducts and nearby mesenchymal tissue form the majority of the female reproductive tract. •The mullerian duct is derived from the coelomic epithelium which according to the theory, has the ability for multipotential development. (possibly as the uterine tissues are migrating toward the pelvis, fragments are left behind) •Endometriosis results from the metaplastic transformation of peritoneal mesothelium into endometrium under unidentified stimuli. •Endometriosis has been found in women who have never menstruated. •Endometriosis has been reported in pre-pubertal females. •Endometriosis occurs in adolescent females without mullerian anomalies and before having many menses. •Endometriosis occurs in unusual sites.

Mullerian (Coelomic) Metaplasia