ENDOMETRIOSIS and ADENOMYOSIS

Stage 1 Minimal disease =1-5 points Stage 2 Mild disease = 6-15 points Stage 3 Moderate = 16-40 points Stage 4 Severe = >40 points

4 stages based on a point scoring system related to type, location and amount of endometriosis present.

1. Exact same thing only still in the uterus but rather than staying in the surface - It has invaded into the myometrium. 2. Endometrium w/ finger like projections growing/invading into myometrium. *** Endometriosis interna is adenoymosis****

ADENOMYOSIS

The extension of endometrial glands and stroma into the uterine musculature. Originally referred to as endometriosis interna.

ADENOMYOSIS

1. Gross appearance consists of diffuse enlargement, thickened myometrium with glandular irregularities. 2. Histologically, may consist of superficial extension of endometrium into the myometrium up to extension throughout the myometrial thickness.

ADENOMYOSIS PATHOLOGY

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.

Adenomyosis

Adenomyosis - muscles can't fully squeeze so you get heavier bleeding - not irregular period - regular excessive bleeding during periods

Adenomyosis

1. Muscle of the uterus - weave of muscle fibers - have perforated blood vessels through myometrium feeding the endometrium 2. These are ripped open when endometrium is pulled off 3. When muscles clamp down it pinches those vessels and slows the bleeding

Normal

*** MOST COMMON is on the OVARIES. --> 60% 2. Other areas are the uterus, utero-sacral ligaments, cul-de-sac and fallopian tube. 3. Also occasionally found in laparotomy scars, umbilicus, pelvic lymph nodes (30 %), and the nose. 4. Has even been found in the lung and brain during autopsies.

OCCURRENCE SITES of Endometriosis

1. 30-50% after medical therapy 2. 14-40% after conservative surgery. (5-20% per year). 3. If during radical surgery an uninvolved ovary is preserved, there is a 6-fold increased risk of recurrent s/s as compared to removing both ovaries.

RECURRENCE of ENDOMETRIOSIS

1. Very Important !!!! 2. Allows you to quantify the severity. (Gives a standardized diagnosis). 3. Guides your treatment. (Medical vs. conservative surgery or aggressive surgery). 4. If you or somebody else has to "go in" a second time, you will know if and how well your previous treatment has worked.

STAGING

Pain of endometrioses is not related to extent of disease but infertility is

STAGING

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. *** The stage has a direct correlation to the severity of infertility.

STAGING

1. Resection 2. Ablation 3. Hysterectomy - If ovaries are not removed, there is a much greater likelihood of recurrence.

SURGICAL MANAGEMENT

1. Menorrhagia --> Increased surface area of endometrial cavity --> Can interfere with the normal contractility of the uterine muscle leading to increased bleeding 2. Severe dysmenorrhea --> More likely when glandular invasion exceeds 80% or more of the endometrium 3. Many patients are asymptomatic

SYMPTOMS of ADENOMYOSIS

*** Spongy, slightly enlarged, boggy ** key words 2. The heavier a woman bleeds, the more clotting and cramping

Signs of ADENOMYOSIS

1. Uterus is symmetrically enlarged. 2. Usually soft and boggy but, it may be asymmetrical and firm. Thus, making it hard to distinguish from a fibroid uterus.

Signs of ADENOMYOSIS

1. Tender fixed adnexal mass on bimanual exam. 2. Frequently find a retroverted uterus in these women. 3. Sharp, firm, very tender "barb" felt on utero-sacral ligaments. "Nodular utero-sacral ligaments".

Signs of Endometriosis

1. Investigate menorrhagia to rule out endometrial cancer. ( D&C or endometrial biopsy). *** A hysterectomy is the one, real cure.

TREATMENT of ADENOMYOSIS

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

The Five Theories of Development Probably all of the above mechanisms play a role but the percentage of each varies with the individual.

More resistance below, the tubes can open up and that is how all the stuff would get out of the uterus and being implanted elsewhere

Theory for Endometriosis

1. Hormonally treating and conservative before here - steroidals OTC and prescription 2. No relief from any of that, then high index of suspicion and laparoscopy

Treatment course with endometriosis

1. Cyclic pelvic pain in association with menses. 2. Infertility.

Usual Presentations of Endometriosis

1. Endometrial epithelium, glands and stroma *** Hemosiderin-laden macrophages

ENDOMETRIOSIS

1. Endometriosis one of the few benign conditions that we stage = that's a cancer thing. Usually don't stage benign processes but gynos are freaks. 2. Stage to monitor the Tx.

ENDOMETRIOSIS

1. Most common to find in the pelvis but can find it elsewhere. Look at bowel, peritoneum off to the sides, etc... 2. Can have 1 of 3 appearances

ENDOMETRIOSIS

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

ENDOMETRIOSIS

Most of the imaging processes (lesions need to be 1cm or bigger to show up and these are like pin hole size) Need to either see it or Bx it. Scope into the belly button.

ENDOMETRIOSIS

We find this laparoscopically. Cannot find on PE. Maybe find suggestive signs? But cannot Dx on PE or with US or w/ CT or MRI. Need to do laparo.

ENDOMETRIOSIS

1. Looks completely different. Doesn't look like a volcano. 2. Irritation/inflammation causes everything around it to swell and the lesion itself is invaginated.

ENDOMETRIOSIS Cryptic

Pigmented is classic - looks dark

ENDOMETRIOSIS Pigmented

1. Lesions where it doesn't have any color - Is still active even though it lacks pigment. 2. Both of These lesions look like a volcano.

ENDOMETRIOSIS Pigmented and Non-Pigmented

1. Both of these conditions are benign. Not pre-malignant. Do not become pre-malignant. And don't become malignant. 2. Benign processes.

ENDOMETRIOSIS and ADENOMYOSIS

Share one thing - the endometrial tissue isn't where it belongs

ENDOMETRIOSIS and ADENOMYOSIS

1. A cyst that forms beneath the surface of the ovary filled with chocolate-colored molasses fluid 2. Usually endometrial glands and stroma are present in the cyst wall 3. Can be adherent to the broad ligament, fallopian tube or pelvic sidewall

Endometrioma

1. Can find studding on the uterosacral ligaments - not pathognomonic 2. Diagnosis with laporoscopy

Endometrioma

1. Can rupture and cause rapid spread of the condition 2. Markedly increases the staging of the endometriosis

Endometrioma

1. Endometriosis doesn't interfere with normal uterine bleeding 2. Pain is usually worse when they are on their period

Endometrioma

1. Endometrial like tissue outside of the uterus 2. Either on serosal surface, peritoneum, supporting ligaments, ovary, vagina, vulva, esophagus, trachea, anywhere on earth. Even in surgical scars of the abdomen.

Endometriosis

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.

Endometriosis

1. Incidence peaks in women in their 40's 2. About 15% of patients with Adenomyosis have associated endometriosis --> Probably even lower than this

INCIDENCE of ADENOMYOSIS

More common in peri-menopausal women

INCIDENCE of ADENOMYOSIS

1. Pigmented 2. Non-Pigmented 3. Cryptic

Implant types - ENDOMETRIOSIS

1. Located on the peritoneum or surface of pelvic structures 2. Endometrial-like tissue responds to cyclic hormonal changes causing local (not vaginal) bleeding, scarring and surrounding fibrosis 3. Responds as if it were still inside the uterus.

Implants: ENDOMETRIOSIS

1. Usually diagnosed in the third decade of life. 2. Usually regresses after menopause however, 5% of women are diagnosed after menopause. 3. Quite often associated with genital outflow tract obstructions in adolescents.

Incidence

1. Isolated implants --> Pigmented --> Non-pigmented --> Cryptic 2. Adnexal mass --> Ovarian endometrioma --> Encapsulating Adhesions 3. Cul-de-sac obliteration

LAPAROSCOPIC FINDINGS

1. Hormonal suppression - oral contraceptives and depo-provera 2. GnRH agonists 3. Pseudopregnancy and pseudomenopause are part of the treatment for this 4. Pregnancy has a suppressive effect but we don't know the mechanism - it just does 5. Hysterectomy in younger woman - PID and endometriosis

MANAGEMENT

1. Medical Treatment has proven effective for pelvic pain. 2. Medical Treatment has not been proven effective for fertility. 3. Surgical and Medical treatments can be used together.

MANAGEMENT

Depends on severity of disease, age of patient, desire for future fertility and the threat of impingement on surrounding organs. 1. Surgical Treatments 2. Medical Treatments 3. Combination Treatment

MANAGEMENT

1. NSAID's - continuous or episodic 2. Oral contraceptives - cyclic or continuous 3. Progestins - continuous 4. Danocrine - continuous BID 5. GnRH agonists --> continuous, monthly: Lupron, Zoladex --> Nasal Spray BID: Synarel

MEDICAL MANAGEMENT

Getting rid of tissue causing pain and hormone causing proliferation

Main idea for treatment

*** The classic way is "Laparoscopy" 2. Visual inspection by an experienced surgeon. 3. Histologic findings (biopsy) --> Can be used in questionable cases. 4. Ultrasound not reliable except for endometrioma. 5. Hemosiderin laden macrophages*****

Diagnosis of Endometriosis

1. Suspected based upon the above signs and symptoms 2. Definitive diagnosis is only possible based upon histologic evaluation after hysterectomy

DIAGNOSIS of ADENOMYOSIS

1. CA 125 can be elevated in many benign conditions in the pre-menopausal pt. 2. CA 125 can be elevated in patients with endometriosis.

DIAGNOSTIC CONFUSION

1. CA 125 is a tumor marker usually associated with ovarian CA. 2. CA125 is a cell surface antigen found on derivatives of coelomic epithelium (inc. endometrial). 3. CA 125 is a better marker in menopausal patients. ** Endometriosis is a benign condition that causes an elevation in CA 125

DIAGNOSTIC CONFUSION

1. Dysmenorrhea ** Pain with menstrual 2. Dyspareunia ** Pain with sex 3. Dyschezia ** Pain with bowel movements

CLASSIC TRIAD OF SYMPTOMS CYCLIC PELVIC PAIN

1. Adenomyosis is usually seen in 30 and 40 year olds. 2. Symptoms include menorrhagia and dysmenorrhea. 3. Definitive treatment is a hysterectomy.

CONCLUSIONS

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.

CONCLUSIONS

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 patients age, extent of disease and desire for future fertility.

CONCLUSIONS

*** Diffuse, non-encapsulated: most common 2. Local, encapsulated: Adenomyoma may project into the uterine cavity making it difficult to differentiate from submucous fibroid

DISTRIBUTION of ADENOMYOSIS