Ch 15 Endometriosis and Adenomyosis

A couple presents because they have been trying to conceive for 18 months. During the interview you learn that the man has fathered a child in a previous relationship and is in good health. The woman is 28 and reports that she has had painful menses for the past 5 or 6 years. 1. You begin to suspect that she may have endometriosis. All of information below would increase that suspicion except: a. she reports that a maternal cousin has a history of endometriosis b. she has experienced dyspareunia with deep penetration for several years c. her ethnicity is Caucasian d. she report the development of abnormal bleeding in the last year e. her menarche began at age 9

A. she reports that a maternal cousin has a history of endometriosis Answer A: Genetic factors probably are associated with the risk of developing endometriosis and an increased risk of developing endometriosis has been observed in first-degree relatives. However, this association has not been observed in third-degree relatives. Other risk factors include Caucasian ethnicity as compared to black or Asian ethnicity and early menarche. The report of deep dyspareunia, dysmenorrhea, and abnormal menstrual bleeding are all symptoms that are associated with endometriosis.

A couple presents because they have been trying to conceive for 18 months. During the interview you learn that the man has fathered a child in a previous relationship and is in good health. The woman is 28 and reports that she has had painful menses for the past 5 or 6 years. 3. After your examination where you did find uterosacral nodularity, you discuss with your patient your concern that she has endometriosis. You recommend that as part of her continued evaluation and treatment for infertility that she undergoes a diagnostic laparoscopy with ablation or excision of endometriosis if it is found. Your patient is very concerned about the diagnosis and wonders what percent of women with infertility have endometriosis. You tell her: a. 10% b. 30% c. 50% d. 70% e. 90%

B. 30% Answer B: Approximately 30% to 40% of women who have infertility also have the diagnosis of endometriosis. The overall incidence of endometriosis in the US population is thought to be approximately 10% to 15%.

A 38-year-old G3P3 woman with 12 months of increasingly heavy menses and worsening dysmenorrhea comes to you for a second opinion. She underwent a pelvic ultrasound that suggested adenomyosis and her gynecologist recommended a hysterectomy. She states that she does not trust the ultrasound results and wants to know if there is anything else that can be done to confirm the diagnosis. What would be the most appropriate next step? a. Review the ultrasound results and reassure her that her gynecologist is correct b. Repeat the pelvic ultrasound c. Tell her that hysterectomy is the only thing that will help to clarify her diagnosis d. Suggest a 3-month trial of an oral contraceptive pill e. Examine her and recommend obtaining a pelvic MRI

E. Examine her and recommend obtaining a pelvic MRI Answer E: Both the examination and the pelvic MRI can increase or decrease the likelihood of adenomyosis and would be the most appropriate next step. Repeat ultrasound is unlikely to add new information to the initial ultrasound. Although hysterectomy may be eventually necessary and ultimately provides tissue to make the definitive diagnosis, MRI is a noninvasive method that is fairly sensitive in this patient looking for a second opinion. An oral contraceptive is used for a number of conditions including adenomyosis. A response or lack of response to it would not necessarily help clarify the diagnosis of adenomyosis.

A 23-year-old G0 woman presents complaining of increasing pelvic pain with her menses over the last year since she stopped her OCPs. In particular, she has noticed more pain on her left side in the last couple of months. She denies any changes in her bladder or bowel habits but reports that she has begun to have pain with deep penetration during intercourse. She started OCPs when she was 17 for painful irregular cycles but stopped them a year ago when her insurance changed. She has had only one lifetime sexual partner and no history of sexually transmitted infections. She would like to preserve fertility. On examination, she has no abnormal discharge but her uterus is tender as well as her left adnexa. You appreciate a fullness that you suspect maybe a mass. On pelvic ultrasound she has a 5 cm cystic ovarian mass thought to be an endometrioma. It persists in repeat ultrasound 8 weeks later and the patient is still symptomatic. 3. Your patient would like to know more about the GnRH agonist, Lupron. You explain how it works and that the side effects include all of the following except: a. hot flashes b. headaches c. decreased bone density d. weight gain e. deepening of the voice

E. deepening of the voice Answer E: Deepening of the voice occurs with an androgen derivative, danazol, which initiates a pseudomenopause state. However, this symptom is not associated with the GnRH agonists. Hot flashes, headaches, decreased bone density, and weight gain can all occur secondary to GnRH agonists such as Lupron that initiate a medical pseudomenopause and create a relatively estrogen deficient state, which helps to prevent the development of new foci of endometriosis.

A 38-year-old G3P3 woman with 12 months of increasingly heavy menses and worsening dysmenorrhea comes to you for a second opinion. She underwent a pelvic ultrasound that suggested adenomyosis and her gynecologist recommended a hysterectomy. She states that she does not trust the ultrasound results and wants to know if there is anything else that can be done to confirm the diagnosis. After you complete your evaluation, you agree that she likely has adenomyosis. She is very busy with work right now and wants to avoid surgery for several months. You recommend one or a combination of the options listed except: a. Levonorgestrel-containing IUD b. NSAID c. oral contraceptive pill d. progestin therapy e. doxycycline for 14 days

E. doxycycline for 14 days Answer E: If you suspected an underlying chronic endometritis or if endometritis was found on endometrial biopsy, then doxycycline may be appropriate. It would not typically be effective for management of her menorrhagia and dysmenorrhea for NSAIDs can be used alone with mild symptoms or in combination with either an oral contraceptive or a progestin. Other than hysterectomy, the levonorgestrel-containing IUD is the most effective treatments for treating the symptoms of adenomyosis.

A 38-year-old G3P3 woman with 12 months of increasingly heavy menses and worsening dysmenorrhea comes to you for a second opinion. She underwent a pelvic ultrasound that suggested adenomyosis and her gynecologist recommended a hysterectomy. She states that she does not trust the ultrasound results and wants to know if there is anything else that can be done to confirm the diagnosis. When discussing hysterectomy and the timing for surgery, she tells you that she has a younger sister who is a 29-year-old G0. Your patient would like to know if her younger sister is likely to develop adenomyosis and subsequent menorrhagia and dysmenorrhea. You explain that all of the following may increase the risk for developing adenomyosis except: a. parous women b. fibroids c. endometriosis d. menopause e. age 30 to 50

D. menopause Answer D: Menopause is not associated with the development of adenomyosis and often symptoms related to adenomyosis will resolve at menopause. Women in their late reproductive years who are parous have an increased risk compared with younger nulliparous women. Endometriosis and fibroids have also been associated with adenomyosis.

A 46-year-old G2P2 obese woman is referred from her primary care physician because of increasingly heavy and painful menses over the last 18 months. She has tried an oral contraceptive with some improvement of her bleeding but no improvement in her pain. She reports no other history of pelvic pain or abnormal bleeding in the past. She has never had an abnormal Pap smear and states she has never had any infections, "down there." Her only medical problems are her obesity, hypertension and gastroesophageal reflux disease. On examination, you note normal external genitalia, vagina, and cervix. However, her uterus is slightly enlarged, mildly tender, and softer than you expected. She has no adnexal mass or tenderness. After further evaluation suggesting adenomyosis, your patient wants to proceed with hysterectomy because she is tired of bleeding and experiencing pain. You explain to her that she needs to undergo a test prior to scheduling her hysterectomy. What test does the patient need to undergo? a. Wet prep b. Endometrial biopsy c. Mammogram d. Colonoscopy e. Chest X-ray

B. Endometrial biopsy Answer B: Because of her abnormal bleeding and age older than 45 and obesity, endometrial biopsy should be performed prior to scheduling hysterectomy to rule out concomitant endometrial hyperplasia or carcinoma. A screening wet prep is not necessary prior to hysterectomy and only needs to be performed if the patient is complaining of symptoms consistent with bacterial vaginosis. Mammography is suggested every 1 to 2 years for women in their 40s but is not required prior to scheduling a hysterectomy. Routine colo-rectal cancer screening with colonoscopy begins at age 50. The patient is not having other symptoms that would require a colonoscopy. Routine chest X-rays are not necessary prior to a major gynecologic procedure and should be reserved for those where there is concern for cardiopulmonary disease.

A 23-year-old G0 woman presents complaining of increasing pelvic pain with her menses over the last year since she stopped her OCPs. In particular, she has noticed more pain on her left side in the last couple of months. She denies any changes in her bladder or bowel habits but reports that she has begun to have pain with deep penetration during intercourse. She started OCPs when she was 17 for painful irregular cycles but stopped them a year ago when her insurance changed. She has had only one lifetime sexual partner and no history of sexually transmitted infections. She would like to preserve fertility. On examination, she has no abnormal discharge but her uterus is tender as well as her left adnexa. You appreciate a fullness that you suspect maybe a mass. On pelvic ultrasound she has a 5 cm cystic ovarian mass thought to be an endometrioma. It persists in repeat ultrasound 8 weeks later and the patient is still symptomatic. 1. What would be the most appropriate next step in her care? a. Resume an oral contraceptive b. Schedule diagnostic laparoscopy with left ovarian cystectomy c. Prescribe an NSAID for her pain and repeat the ultrasound in 6 to 8 weeks d. Prescribe a GNRH agonist (i.e., Depo-Lupron) e. Refer her to a gynecologic oncologist

B. Schedule diagnostic laparoscopy with left ovarian cystectomy Answer B: This patient's history, examination, and ultrasound findings are consistent with endometriosis. Because of her significant symptoms and the findings of a persistent endometrioma, laparoscopy with planned cystectomy is the best option for her. Large endometriomas are not likely to resolve on their own with time in contrast with functional ovarian cysts. They are also unlikely to respond to medical management with an oral contraceptive or GNRH agonist. In this young woman with findings consistent with an endometrioma, referral to an oncologist would not be necessary because of low risk of malignancy and because sensitivity with ultrasound to correctly diagnose endometriomas is high.

A 46-year-old G2P2 obese woman is referred from her primary care physician because of increasingly heavy and painful menses over the last 18 months. She has tried an oral contraceptive with some improvement of her bleeding but no improvement in her pain. She reports no other history of pelvic pain or abnormal bleeding in the past. She has never had an abnormal Pap smear and states she has never had any infections, "down there." Her only medical problems are her obesity, hypertension and gastroesophageal reflux disease. On examination, you note normal external genitalia, vagina, and cervix. However, her uterus is slightly enlarged, mildly tender, and softer than you expected. She has no adnexal mass or tenderness. Which of these diagnoses is the least likely choice to keep in your differential? a. Leiomyoma b. Adenomyosis c. Irritable bowel syndrome d. Endometrial hyperplasia e. Endometriosis

C. Irritable bowel syndrome Answer C: Although irritable bowel syndrome is associated with pelvic pain and is likely underdiagnosed, it is not associated with menorrhagia or dysmenorrhea in particular. Leiomyomas are commonly associated with menorrhagia and sometimes dysmenorrhea. Two of the hallmarks for adenomyosis are menorrhagia and dysmenorrhea especially when it develops in women who are 30 to 50 years of age. Endometrial hyperplasia must be considered in an obese woman with hypertension and abnormal bleeding, especially if she is older than 45 years. Endometriosis would be less likely due to the age at which the onset of symptoms of abnormal bleeding and dysmenorrhea started. Typically these begin to present in the second and third decade. However, adenomyosis, endometriosis, and leiomyomas often coexist.

A couple presents because they have been trying to conceive for 18 months. During the interview you learn that the man has fathered a child in a previous relationship and is in good health. The woman is 28 and reports that she has had painful menses for the past 5 or 6 years. After completing your history you explain to your patient that you need to perform an examination before making any recommendations. You explain that women with endometriosis often have a normal examination but that there are certain findings that are associated with endometriosis. During your examination, which of the findings listed below would NOT increase your suspicion that she has endometriosis. a. A fixed deviated uterus b. Uterosacral nodularity on rectovaginal examination c. Tender adnexa d. An enlarged irregular uterus e. A fixed adnexal mass

D. An enlarged irregular uterus Answer D: An enlarged irregular uterus is typically associated with leiomyomas and not necessarily with endometriosis, although the two can be found concomitantly. Physical findings with early stage endometriosis can be subtle or nonexistent. However, with more disseminated disease a clinician may find uterosacral nodularity on rectovaginal examination, a fixed often retroverted uterus, tender adnexa, and/or a fixed adnexal mass when a large endometrioma is present.

A 23-year-old G0 woman presents complaining of increasing pelvic pain with her menses over the last year since she stopped her OCPs. In particular, she has noticed more pain on her left side in the last couple of months. She denies any changes in her bladder or bowel habits but reports that she has begun to have pain with deep penetration during intercourse. She started OCPs when she was 17 for painful irregular cycles but stopped them a year ago when her insurance changed. She has had only one lifetime sexual partner and no history of sexually transmitted infections. She would like to preserve fertility. On examination, she has no abnormal discharge but her uterus is tender as well as her left adnexa. You appreciate a fullness that you suspect maybe a mass. On pelvic ultrasound she has a 5 cm cystic ovarian mass thought to be an endometrioma. It persists in repeat ultrasound 8 weeks later and the patient is still symptomatic. You perform a laparoscopic left ovarian cystectomy and note that the cyst is a "chocolate cyst." She also has other superficial implants of endometriosis on the uterosacral ligaments. The final pathology report is consistent with an endometrioma. At your patient's postoperative visit 2 weeks after surgery she tells you that her pain is resolved and she is feeling well. What do you recommend for the continued postoperative management of her endometriosis? a. Because endometriosis cannot be cured medically, she should undergo total hysterectomy with bilateral salpingo-oophorectomy b. You were able to completely remove the cyst, so she does not need any further therapy at this time c. Wait 6 months and then schedule a repeat laparoscopy to make sure there is no further endometriosis that needs to be treated d. Initiate therapy with a combined oral contraceptive or a progestin to delay the return of her previous symptoms e. Endometrial ablation because that will destroy her endometrium and decrease the risk of new implants developing from retrograde menstruation

D. Initiate therapy with a combined oral contraceptive or a progestin to delay the return of her previous symptoms Answer D: For patients with pain who do not desire pregnancy, pain control can be optimized and recurrence delayed by starting medical therapy immediately after surgical treatment. For patients who desire fertility in the future, hysterectomy is not an appropriate option. Even though removal of the cyst significantly decreases the risk of endometrioma recurrence, the patient is at increased risk of developing the return of her symptoms and new implants with expectant management compared to medical therapy to suppress recurrent endometriosis and symptoms. Because of the risks of surgery and unlikely return of symptoms within 6 months, medical therapy would be the most appropriate initial step. Endometrial ablation is not recommended for those desiring pregnancy in the future and has not been shown to decrease the risk of recurrent symptoms from endometriosis.

A 46-year-old G2P2 obese woman is referred from her primary care physician because of increasingly heavy and painful menses over the last 18 months. She has tried an oral contraceptive with some improvement of her bleeding but no improvement in her pain. She reports no other history of pelvic pain or abnormal bleeding in the past. She has never had an abnormal Pap smear and states she has never had any infections, "down there." Her only medical problems are her obesity, hypertension and gastroesophageal reflux disease. On examination, you note normal external genitalia, vagina, and cervix. However, her uterus is slightly enlarged, mildly tender, and softer than you expected. She has no adnexal mass or tenderness. You explain to your patient that you think she may have adenomyosis and that it is most likely causing her symptoms. However, you would like to make sure whether or not she has fibroids as well. You explain that she will need an imaging study to help clarify this. Which study listed below would best differentiate between adenomyosis and uterine fibroids? a. Pelvic ultrasound b. Pelvic CT c. Sonohysterogram d. Pelvic MRI e. Hysterosalpingogram

D. Pelvic MRI Answer D: Pelvic MRI is the most accurate imaging tool for identifying adenomyosis. Because the cost of MRI can be prohibitive, ultrasound is the most common means of diagnosis. If there is difficulty in differentiating between uterine fibroids and adenomyosis, then MRI is used. CT imaging is not a helpful tool in evaluating for adenomyosis. Sonohysterography is typically used to screen for intracavitary lesions such as endometrial polyps or submucosal fibroids. Hysterosalpingography is typically used to evaluate the uterine cavity and the patency of the fallopian tubes.