GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)
GYNECOLOGY – ENDOMETRIOSIS AND
ADENOMYOSIS – DR. REYES
(Powerpoint 2017, JT III trans, Caramelmacchiato trans, recordings (blue),
samplex (red). STUDY AT YOUR OWN RISK)
ENDOMETRIOSIS
 Samplex: The presence and growth of the glands and stroma of the
lining of the uterus in an aberrant or heterotopic location
(ectopically located)
 Samplex: A benign but progressive disease
o Prevalence in general female population: 6-10%
o 5-15% of laparotomies on reproductive-age women
o 33% of women with chronic pelvic pain
o 30-45% of women with infertility
THEORIES ON ITS ETIOLOGY
 Retrograde menstruation
 Lymphatic and Vascular dissemination
 Metaplasia
 Genetic predisposition
 Immunologic changes
 Hormonal influences
*There is increasing evidence that environmental factors also play a role, e.g.
exposure to dioxin & endocrine disruptors
RETROGRADE MENSTRUATION:
 Most common and logically explained cause (OVARY: most
common site)
 Remember the uterus is like a sponge, when you have your
menses.. the reason why you’re having crampy pain is because the
uterus is contracting, and when it contracts, remember during
menstruation you don’t only discharge blood or blood clots yung
description ng pasyente parang atay but sometimes you see pale
pink tissues these are endometrial tissues that tends to slough off
or shed off during menstruation. Yun naman yung reason for
menstruation, nagsheshed off yung endometrium.
 Implantation of endometrial cells shed during menstruation,
growing as homologous grafts under hormonal influence
 Endometriosis is discovered most frequently in areas immediately
adjacent to the tubal ostia or in the dependent areas of the pelvis.
o Now by virtue of gravity, it will be discharged
downwards out of the vagina
o But remember, when the uterus contracts, sometimes,
remember there’s a hole diba, the ostia of the fallopian
tube on each side of the uterus it may gain access to the
fallopian tube and where will it first drop? Sa ovary.
Kaya the most common site of endmetriosis is the ovary
kase sya yung unang babagsakan.
 When we say retrograde, paatras
 Endometriosis is frequently found in women with outflow
obstruction of the genital tract. (cervical stenosis, vaginal septum,
uterine septum particularly the transverse septum)
 Dahil retrograde, aside from the ovaries, they may implant also on
the lower abdominal cavity kase they usually implant on dependent
areas of the pelvis
METAPLASIA:
 Endometriosis arises from metaplasia of the coelomic (rare areas)
epithelium or proliferation of the embryonic rests.
 Occurs after an “induction phenomenon” has stimulated the
multipotential cells
o Induction phenomenon once it occurs at the time of
puberty, when estrogen goes up. It will start to
proliferate
 The induction substance may be a combination of menstrual debris
and the influence of estrogen and progesterone.
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o Remember, that endometrium responds to estrogen
and progesterone. If the endometrial lining inside the
uterus menstruates, it also menstruates, it will also
bleed
LYMPHATIC AND VASCULAR METASTASIS:
 The endometrium is transplanted via lymphatic and the vascular
system
o Sabi nila the endometrium @#$%^& (nag-rap si doc di
ko naintindihan).. endometrial lining.. there will be
blood vessels within the basalis layer of the
endometrium and the endometrial lining may gain
access to those vessels and be transported else where.
Pwedeng lymphatic spread
 This theory explains the rare and remote sites of endometriosis,
such as the spinal column and nose.
 Endometriosis has been observed in the pelvic lymph nodes of
approximately 30% of women with the disease.
 Hematogenous dissemination of endometrium is the best theory
to explain endometriosis of the forearm and thigh, as well as
multiple lesions in the lung.
IATROGENIC DISSEMINATION:
 Means induced
 Endometrial glands and stroma are implanted during surgical
procedure
o Example, CS. May endometrial tissue na nadala at
dumikit sa subcutaneous kaya pwedeng magkaroon ng
endometriosis of the abdominal incision
o Or, when the patient delivers vaginally and you did
episiotomy site tapos pwedeng naembed mo while
suturing the episiotomy site during episiorrhaphy,
pwedeng naembed mo, pwedeng magkaroon ng vaginal
endometriosis
 The aberrant tissue is found subcutaneously at the abdominal
incision.
IMMUNOLOGIC CHANGES:
 Changes in the immune system, especially altered function of
immune-related cells, cell-mediated and humoral components of
the immune system
 the primary immunologic change involves an alteration in the
function of the peritoneal macrophages so prevalent in the
peritoneal fluid of patients with endometriosis.
o Usually doon sa pelvic area
 It has been hypothesized that women who do not develop
endometriosis have monocytic-type macrophages in their
peritoneal fluid that have a short life span and limited function.
 Those who develop endometriosis have more peritoneal
macrophages that are larger.
 These hyperactive cells secrete multiple growth factors and
cytokines that enhance the development of endometriosis.
 Hypothesis: Peritoneal macrophages
 refer to the picture sa next page:
o Normal: lack of membrane function, low expression of
enzymes, no increase in size
o In the peritoneal cavity, peritoneal fluid, the
macrophage tends to grow larger in the process
o As they attack the ectopically implanted endometrial
cells, they also invite or increase the production of
cytokines. Eh alam naman natin na ang cytokines and
growth factors may be involved in inflammatory process
o Actually these implanted tissues will later undergo
scarring
 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)

*this is the endometrium in a disease free woman. In the endometrium.. sa

ovary nyo lang mahahanap yung aromatase diba? Saang cell? Sa granulosa.
Yun yung nagcoconvert ng androstenedione to estradiol. Sa endometrium
wala yan. That’s why you do not really have estrogen in the endometrium of
women na disease free or who do not have endometriosis.
*Pero those who have endometriosis tend to have aromatase. And this will
increase estrogen production. And that’s the culprit. That’s the one that
further stimulates the proliferation of this endometriotic implants.
*The thing is true in ectopic endometrial tissues, since may aromatase yung
ectopic endometrial tissues there will be a lot of estrogen. Ang problema sa
ectopic endometrial tissue, you lack the enzyme, the hydroxysteroid
dehydrogenase enzyme that degrades estradiol to the less potent estrone.
That’s why they may continue to proliferate even though they are ectopically
located.
* So the culprit for the growth of endometriosis is ESTROGEN

GENETIC PREDISPOSITION:
 Documented cases of familial predisposition
o Sevenfold increase in the incidence of endometriosis in
relatives of women with the disease.
o The incidence of endometriosis in first-degree relatives
(sister, mother), women with severe endometriosis, has
been thought to be 7%.
o Women who have a family history of endometriosis are
likely to develop the disease earlier in life and to have
more advanced disease.
o Deletion of genes, specifically increased heterogenicity
of chromosome 17 and aneuploidy

Table 19-2 Genes and Gene Products Aberrantly Expressed in

Endometrium from Women with Endometriosis
- Aromatase
- Endometrial bleeding factor
- Hepatocyte growth factor
- 17β-hydroxysteroid dehydrogenase (baka hindi sya naexpress kaya hindi
nadowngrade yung estradiol to estrone)
- HOX A10
- HOX A11
- Leukemia inhibitory factor
- Matrix metalloproteinases 3, 7 and 11
- Tissue inhibitors of metalloproteinases
- Progesterone-receptor isoforms
- Complement 3
- Glutathione peroxidase
- Catalase
- Thrombospondin 1
- Vascular endothelial growth factor
- Integrin αvβ3
- Glycodelin

PATHOLOGY
 Majority of implants are located in the dependent portions of the
pelvis
 The OVARIES are the most common site
 Mostly bilateral
ANATOMIC DISTRIBUTION
COMMON SITES RARE SITES
- Ovaries - Umbilicus
- Pelvic peritoneum - Episiotomy scar
- Uterine ligaments - Bladder
- Sigmoid colon - Kidney
- Appendix - Lungs
- Pelvic LN - Arms
- Cervix - Legs
- Vagina - Nasal mucosa
- Fallopian tubes - Spinal column

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 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)

Table 19-4 Preoperative Symptoms in 130 Patients Undergoing Colorectal  With time the areas of endometriosis become larger and assume a
Resection for Endometriosis light or dark brown color, and they may be described as“powder
Symptom No. of Patients (%) burn” areas or “chocolate cysts.”
Pelvic pain 111 (85)  Older lesions are white, have more intense scarring, and are usually
Rectal pain 68 (52) puckered or retracted from the surrounding tissue.
o Scarring is the one that causes immobility in the side
Cyclic rectal bleeding 24 (18)
plus the pain
Diarrhea 55 (42)
Constipation 53 (41)
Endometriosis Endometrioma
Diarrhea and constipation 18 (14)
Dyspareunia 83 (64)
*Pelvic pain is the most common symptom
*Rectal pain, depende kase kung san sya nagging invasive or kung san sya
nagkaroon ng adhesions kaya masakit

DISEASE OF CLINICAL CONTRAST

CHARACTERISTICS CONTRASTS
Benign disease - Locally invasive
- Widespread disseminated foci
- Proliferates in pelvic LN
Minimal disease - Severe pain CARDINAL HISTOLOGIC FEATURES: (2 out of 3)
Many large endometriomas - Asymptomatic patient  Ectopic endometrial glands (most of the time)
Cyclic hormones cause growth - Continuous hormone reverse growth  Ectopic endometrial stroma (most of the time)
pattern  Hemorrhage into the adjacent tissue
 Previous hemorrhage can be discovered by identifying large
 Deep lesions, penetrations of greater than 5 mm, represent a more macrophages filled with hemosiderin near the periphery of the
progressive form of the disease. lesion.
 Deep endometriotic ovarian cysts and cul-de-sac nodules is  The aberrant endometrial glands and stroma respond in cyclic
important for therapy which require a surgical approach. fashion to estrogen and progesterone
 10% to 15%ofwomen with advanced disease have lesions involving
the rectosigmoid.

GROSS PATHOLOGIC CHANGES

 Visual manifestation is protean and have many appearances
 The gross appearance of the implant depends on the site, activity,
relationship to the day of the menstrual cycle, and chronicity of the
area involved.
o Site: Kung malapit sya sa blood vessel, ang kulay nyan
ay red
o Activity: If it is active, red also in color. Pero pag old na
CLINICAL PRESENTATION
sya nagiging dark brown
o Relationship to the day of menstrual cycle: usually it is SYMPTOMS
bigger and more inflamed during menses  One in 3 women are asymptomatic
 The predominant color depends on the blood supply and the
amount of hemorrhage and fibrosis Classic symptoms:
 The color of the lesion varies widely and may be red, brown, black,  Cyclic pelvic pain
white, yellow, pink, clear, or a red vesicle. (most common is red, o The chronic pelvic pain usually presents as secondary
brown and black) dysmenorrhea or dyspareunia (or both). (if there are
massive scarring and adhesions)
TERMINOLOGIES USED TO DESCRIBE PERITONEAL ENDOMETRIOSIS o Secondary dysmenorrhea usually begins 36 to 48 hours
Powder-burn, puckered black Discolored area prior to the onset of menses (yung time na
lesions Yellow-brown pinakamasakit sya ay between the 2nd and the 3rd day of
Vascular glandular papules Blue menses)
Vesicular lesions White o The cyclic pelvic pain is related to the sequential
-Serous, surrounded by marked White scarring swelling and the extravasation of blood and menstrual
vascularization Peritoneal defects debris into the surrounding tissue.
-Red hemorrhage Cribriform peritoneum o The chemical mediators of this intense sterile
Red, flame-like Suborvarian adhesions inflammation and pain are believed to be
Petechial peritoneum prostaglandins and cytokines
Hypervascularized area
 Infertility
o Why would you develop infertility? Remember, if there
 New lesions are small,bleb-like implants that are less than1 cm in
is massive scarring in the area this may kink the fallopian
diameter. (they are usually small, but in time, if they tend to bleed
tubes. Eh kapag nag kink yun na yung tinatawag nating
they will tend to accumulate blood and the blood will distend the
tubal factor infertility and it may affect oocyte function
cyst kaya lumalaki sya eh kase it menstruates everytime the
o Dyspareunia associated with endometriosis is described
patients have their menses)
as pain deep in the pelvis.

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 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)

o The cause of this symptom seems to be immobility of Endometriosis < 1cm 1-3 cm > 3cm
the pelvic organs during coital activity or direct pressure Superficial 1 2 4
on areas of endometriosis in the uterosacral ligaments Deep 2 4 6
or the cul-de-sac.
R superficial 1 2 4
o The acute pain, experienced during deep penetration,
may continue for several hours following intercourse. Deep 4 16 20
L superficial 1 2 4
Speculum examination Deep 4 16 20
 may demonstrate small areas of endometriosis on the cervix or Posterior cul de PARTIAL 4 COMPLETE 40
upper vagina. sac obliteration
 Lateral displacement or deviation of the cervix is visualized or ADHESIONS < 1/3 1/3-2/3 > 2/3
palpated by digital exam of the vagina and cervix in approximately ENCLOSURE ENCLOSURE ENCLOSURE
15% of women with moderate or severe endometriosis. R filmy 1 2 4
o Nagkaroon ng lateral displacement because there was
Dense 4 8 16
adhesion and there was traction/pulling effect on the
cervix because of the adhesions and scarring pero hindi F filmy 1 2 4
pa din yun ganun kaspecific Dense 4 8 16
R filmy 1 2 4
SIGNS Dense 4 8 16
 Classic Pelvic Finding: L fimly 1 2 4
o Fixed retroverted uterus (tip of the fundus or the fundus Dense 4 8 16
is tilt towards the rectum), with scarring and tenderness
posterior to the uterus
o Tenderness of the pelvic structures, nodularity of the Stage I (minimal) 1-5
uterosacral ligaments and cul-de-sac Stage II (mild) 6-15
o Time of maximum swelling and tenderness – first 2 days Stage III (moderate) 16-40
of menses Stage IV (severe) > 40
o first or second day of menstrual flow is the time of
maximum swelling and tenderness in the areas of STUDY!!!
endometriosis
o Advanced cases have extensive scarring and narrowing
of the posterior vaginal fornix (usually yan na yung stage
4)
o The ovaries may be enlarged and tender and are often
fixed to the broad ligament or lateral pelvic sidewall.

LAPAROSCOPY
 Gold standard for diagnosis (you can really see if there are implants
in the area; both diagnostic and therapeutic)
 Staged according to the updated scoring system of the American
Society of Reproductive Medicine
 The focus was intended to provide characterization of disease
extent for fertility and not for pain assessment.
 Diagnosis based on laparoscopic visualization of endometriotic
implants alone is unreliable
 Overall positive predictive value: 43-45 %

STAGING: REVISED AFS SYSTEM

 Ranges from Stage I (Minimal) to Stage IV (Severe)
o Location and Depth of Disease
o Extent of Adhesions

*Sample questions sa staging

- there were 0.5 cm deep lesions note don the R ovary with filmy adhesion:
Stage 1
- there is a 2 cm deep lesion in the R ovary with partial obliteration of cul de
Hints (From JT III)
sac: Stage 3
Stage 1 Unilateral superficial involvement of ovary
- on evaluation of the pelvis there are dense adhesions both the ovary and
Stage 2 Both superficial ovaries involved
fallopian tube on the L have deep lesions: Stage 4
Stage 3 Partial obliteration of Cul de sac
Both deep ovaries involved; if no cul de sac obliteration
Dense/deep adhesions
Stage 4 Involvement of other organs (Fallopian tube)
Complete obliterated Cul De Sac

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 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)
OTHER DIAGNOSTIC TOOLS:
 Ultrasound
o Ultrasound examination shows no specific pattern to
screen for pelvic endometriosis
o helpful in differentiating solid from cystic lesions and
may help distinguish an endometrioma from other
adnexal abnormalities.
o The lesions are vascular, increased Doppler flow may be
demonstrated in endometriosis
 MRI
o Provides the best diagnostic tool for endometriosis
o Not always a practical modality for its diagnosis.
COURSE OF DISEASE
 Serial pelvic examinations are a poor indicator of progression of the
disease. Serum levels of cancer antigen-125 (CA-125) have been
used as a marker for endometriosis.
 Generally, it is thought that endometriosis improves during
pregnancy
 Increase in lesions has been documented, primarily in the first
trimester.
 Ovarian endometriomas, which may have a different pathogenetic
origin, from surface implants of endometriosis on the ovary may
persist during pregnancy.
 Ovarian endometriosis rupture during pregnancy may occur.
 CA-125 levels are elevated in most patients with endometriosis and
increases incrementally with advanced stages.
o low specificity
o increase with other pelvic conditions such as
leiomyomas, acute pelvic inflammatory disease, and the
first trimester of pregnancy.
 Glycodelin
o AKA placental protein 14
o Elevated in endometriosis and is produced in
endometriotic lesions.
o Levels fall with removal of the disease.
o Glycodelin has not proved to be useful clinically.
*Diagnosis is clinical. Diagnostic tests are just supportive
MANAGEMENT
 Short –term goals:
o Relief of pain
o Promotion of fertility
 Long-term goals:
o Prevent progression or recurrence
 Treatment plans must be individualized
 Forms of treatment:
o Medical
o Surgical
o Combination of medical and surgical
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MEDICAL MANAGEMENT: HORMONAL THERAPY
 Aimed at suppression of lesions and associated symptoms,
particularly pain.
o Best indicator to say that you are treating the lesion:
you look at the endometrial lining by ultrasound. Your
goal is to thin out the endometrium even at atrophic
levels. Ano ba yung atrophic? Less than 0.5 cm or less
than 5mm. because if the endometrium is atrophic, do
you agree that the ectopic glands will also become
atrophic? YES
o This is best achieved Induction of amenorrhea, without
inducing hypoestrogenism.
o recurrence rate following medical therapy is 5% to 15%
in the first year and increases to 40% to 50% in 5 years.
o suppresses symptomatology and prevents progression
of endometriosis, but it does not provide a long-lasting
cure of the disease.
 Agents used:
o Goal nilang lahat (except NSAIDs) is to reduce estrogen
levels, the estrogen’s influence on the endometrium.
What causes the proliferation of the endometrium?
Estrogen. So if we reduce the action of estrogen,
nothing will proliferate the endometrium as well as the
ectopically located glands and stroma
o Danazol
o GnRH agonists
o Oral contraceptives
o NSAIDs (for pain)
o Other hormonal agents
 Progestins
 Gestrinone
 Cox-2 inhibitors
 Aromatase inhibitors
 PPAR-ligands
DANAZOL
 Attenuated androgen that is active when given orally.
 Chemically it is a synthetic steroid that is the isoxazole derivative of
ethisterone (17-a-ethinyltestosterone)
 Approximately three of four patients note significant improvement
in their symptoms, and about 90% have objective improvement
discovered at second-look laparoscopy.
 ACTION:
o Inhibits midcycle LH surge → chronic anovulation
o Inhibits steroidogenic enzymes → hypoestrogenic
o Increases free testosterone → androgenic and anabolic
o Induces atrophic changes in the endometrium of the
uterus and similar changes in endometrial implants
o OTHER ACTION: modulate immunologic function
 The standard length of treatment: 600-800 mg daily dose 6 to 9
months.
 OUTCOME:
o Three or four patients note significant improvement in
their symptoms
o 90% have objective improvement discovered at second-
look laparoscopy
 Has substantial androgenic and hypoestrogenic side effects:
Weight gain Hirsutism
Fluid retention Atrophic vaginitis
fatigue Hot flushes
Decreased breast size Muscle cramps
Acne Emotional lability
Oily skin Increases total cholesterol and LDL
and lowers HDL
 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)
GnRH AGONISTS
 It’s a peptide based agent. Remember protein and peptide based
agents are never given orally. The reason for this is, pag binigay mo
ng oral, may peptidases sa stomach, madedegrade sya, pag binigay
mo sa blood may dipeptidases. So bigay mo na lang sya IM,
sustained release sya eh.
 But remember, what is the dictum with GnRH? It is released from
the hypothalamus by pulses. What’s the reason why it is released
by pulses? Remember what happens to the receptor on the
gonadotrophs? San nakikita ang gonadotrophs? Anterior pituitary
diba. Once the GnRH is released from the hypothalamus it goes to
the GnRH receptors on gonadotrophs found in the anterior
pituitary gland. Once it attaches to the receptor, the receptor
undergoes internalization. That’s the reason why it has to be
released by pulses. To allow the receptor to resurface. If you give it
tonically, if you give it continuously sustained release, what will
happen to the receptors? Mawawala and you call that
downregulation. You lose the availability of the receptors. It
becomes inhibitory now. Hence you do not ovulate at the same
time will you have estrogen and progesterone? NO. will the
endometrium and implants proliferate? NO. Will you treat the
problem? YES. Ang dali lang diba? (Me: NOOOO. Hahaha)
 Representative agonists
Leuprolide acetate The usual dose is 3.75 mg intramuscularly once
(Lupron, injectable) per month or a 11.25-mg depot injection every
3 months.
Nafarelin acetate given in a dose of one spray (200 mg) in one
(Synarel, intranasal) nostril in the morning and one spray (200 mg) in
the other nostril in the evening up to a
maximum of 800 mg daily.
Goserelin acetate given in a dosage of 3.6 mg every 28 days in a
(Zoladex, biodegradable subcutaneous implant.
subcutaneous implant)
 Best used in Endometriosis associated with severe pain
 establishing the optimal dose to produce sufficient down
regulation and desensitization of the pituitary to produce
extremely low levels of circulating estrogen and amenorrhea.
 MECHANISM OF ACTION:
o Downregulation and desensitization of the pituitary to
produce extremely low levels of circulation estrogen
and amenorrhea
 Chronic use of GnRH agonists produces a “medical oophorectomy.”
(medical menopause)
 The greatest therapeutic effects with areas of endometriosis are
less than 1 cm in diameter
 GnRH agonist therapy ameliorates symptomatology in 75% to 90%
of patients depending on the extent of the disease
 Ovarian function usually returns to normal in 6 to 12 weeks after 6
months of GnRH agonist therapy
 Other side effects:
Decreased libido Fatigue
Depression Headache
Irritability Changes in skin texture
Effects:
 No effect on sex hormone-binding globulin.
 No androgenic side effects
 No significant changes occur in total serum cholesterol, HDL, or LDL
levels during therapeutic periods of as long as 6 months.
 Endometrial samples obtained after several months of chronic
agonist therapy demonstrated either atrophic or early proliferative
endometrium.
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Side Effects:
 The three most common symptoms are hot flushes, vaginal
dryness, and insomnia.
 A decrease in bone mineral content has been demonstrated in the
trabecular bone of the lumbar spine
 GnRH agonist therapy ameliorates symptomatology in 75% to 90%
of patients with endometriosis, depending on the extent of the
disease in the study group.
 Growth of endometriosis is arrested, diminished, or eliminated.
 The greatest therapeutic effects are seen in patients whose areas
of endometriosis are less than 1 cm in diameter.
 Ovarian function usually returns to normal in 6 to 12 weeks after 6
months of GnRH agonist therapy
 The primary advantage of GnRH agonists over danazol is better
patient compliance.
 Most patients find the side effects of GnRH agonists more
tolerable.
 Currently, “add back” hormone replacement therapy with dosages
similar to menopausal therapy in combination with chronic GnRH
agonist regimens.
 The clinical hypothesis is that the add-back medication will reduce
or eliminate the vasomotor symptoms and vaginal atrophy and also
diminish or overcome the demineralization of bone.
ORAL CONTRACEPTIVES
 You give it continuously; ito kase hindi for contraception. Ang gusto
natin ay masuppress talaga natin
 Monophasic pill/day for 6-12 months
o Same dose all throughout
o Yung amount ng estrogen and progesterone sa pill, from
pill 1 to pill 24 is the same
o Do not give biphasic, triphasic kase dito tumataas or
bumababa yung hormones. Baka pag tumaas,
magproliferate yung ectopic glands and stroma
 Induces amenorrhea and decidualization
o Isa pang marker ay amenorrhea. Pag nag amenorrhea
na yung patient ibig sabihin masyado nang manipis yung
lining ng uterus. Its atrophic kaya di na sya
nagmemenstruate. Ibig sabihin effective yung gamut
o This is what we want. To induce amenorrhea. It is an
indirect marker that there is atrophy of the lining of the
uterus
 High estrogen, high progesterone environment
 Enhances endometrial cell apoptosis
 Given to produce amenorrhea and a “pseudopregnancy.”
 One potential risk of using oral contraceptives or progestogens: risk
of rupture if a large endometrioma is present.
 Rupture of large endometriomas may result during the first 6
weeks of oral contraceptive therapy.
 During prolonged therapy the endometrial glands atrophy and the
stroma undergoes a marked decidual reaction.
o Bakit magkakaroon ng endometrial gland atrophy? Eh
nagbibigay ako ng estrogen plus progesterone na
contraceptive pill.
o Your ovaries are producing their own hormones.
Correct? Yes. And yet you give exogenous hormones.
And so what happen? Excess. Then, negative feedback.
Hence you will not produce enough estrogen to make
that gland and stroma proliferate.
o Only given to small lesions. Large lesions = surgery
 Some smaller endometriomas (3 cm) can undergo necrobiosis and
resorption.
 The most common side effects include weight gain and breast
tenderness.
 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Advantages:

 Beneficial for pain relief and as concomitant therapy may improve  Both diagnostic and therapeutic
the bleeding control of patients on oral contraceptives.  Shorter recovery period
 lesions of endometriosis – express high levels of Cox-2  Reduced subsequent postoperative
adhesions
OTHER HORMONAL TREATMENTS
PROGESTOGENS: COMBINATION OF MEDICAL AND SURGICAL THERAPY
 What’s the effect of progesterone? It counteracts the effects of  For advanced stages of endometriosis
estrogen on the lining of the uterus. It will tend to reduce the  Many favors preoperative medical therapy prior to surgery,
number of estrogen receptors. It increases amount of estradiol especially in extensive disease
dehydrogenase which will now degrade estradiol to estrone  Postoperative medical therapy is considered depending on the
 One effect is thinning out of the endometrium extensiveness of the disease and the success of surgery
 Induces endometrial attenuation  Depends on what you see. You see a lot of implants in the area,
 High doses inhibit ovulation → cause prolonged amenorrhea maraming areas of decidualization, madaming implants. You need
 Suppresses expression of endometrial matrix metalloproteinases to give medical therapy after surgery particulary conservative
 most appropriate for the older woman who has completed surgery.
childbearing
 For women who cannot tolerate the high dosage of estrogen in an
oral contraceptive
 Who have a contraindication to estrogen therapy
o Medroxyprogesterone acetate (Provera) - 20 to 30 mg
orally per day
o Depo-medroxyprogesterone acetate (Depo-Provera) -
150 mg intramuscularly every 3 months to a maximum
of 200 mg every month
o Norethidrone acetate 5-20 mg/day
o Megestrol acetate 40 mg/day
o Levonorgestrel-containing IUD (mas maganda sa
adenomyosis)
o Gestrinone 2.5 to 7.5 mg/week
o Dienogest 2 mg/day (newest)

SURGICAL THERAPY
 Treatment for women with moderate or severe endometriosis
 Especially those with adhesions and when the disease involves non-
reproductive organs.
 Mandatory in cases involving acute rupture of large
endometriomas (cut off nung iba is 4 or 5 cm. wag mo na imedical
treatment yun, magrurupture lang yun. Surgical na yun), ureteral
obstruction, compromises in intestinal function, or for large
ovarian endometriomas
 Factors to consider between medical or surgical management:
o Age
o Symptomatology
o Reproductive desires (if completed reproductive career,
pwede na radical surgery)
TYPES
 Conservative surgery:
o Resection or destruction of endometrial implants, lysis
of adhesions and attempts to restore normal anatomy
o Removal of all macroscopic, visible areas of
endometriosis with preservation of ovarian function
and restoration of pelvic anatomy
o Laparoscopy is commonly recommended
 Definitive surgery:
o Removal of both ovaries, the uterus and all visible
ectopic foci of endometriosis
o Reserved for far advanced disease and for whom future
fertility is not a consideration
o TAHBSO and removal of all visible endometriosis
 Laparoscopy:
o Gold standard
o employed for both diagnostic and therapeutic reasons
o Commonly recommended as initial approach
 History and PE consistent with adnexal mass, 7cm. you may need
surgery. But if the mass is 3cm or less, you may need to observe
and medical management to relieve the symptoms.
 The treatment depends on the presentation of your patient. If no
improvement you may start with oral medications. If no
improvement you may give GnRH. But if there’s no improvement
consider laparoscopy. Or after 3 months of treatment hindi lumiit
you may consider laparoscopy. Dapat kase magrespond sya in 3
months
THERAPY FOR FERTILITY
 Surgery is the initial approach, especially laparoscopy
 Symptomatic women with ovarian endometriomas, laparoscopic
surgical excision should be undertaken
 Medical therapy cannot be first-line because suppression of
ovulation interferes with the ability to conceive.
 It is debated whether treating mild endometriotic lesions or
implants will improve fertility
MECHANICAL FACTORS AFFECTING PREGNANCY RATES
1. Endometriomas
2. Adhesions
3. Fibrosis
 Macrophage and cytokine abnormalities are thought to play a
significant role in inhibiting fertility
 These factors may affect oocyte quality, fertilization, and embryo
quality as well as endometrial receptivity.
 Therefore, in addition to ablating lesions when present, several
strategies have been devised to enhance fecundity.
 Controlled ovarian stimulation and intrauterine insemination, an
approach to enhance fecundity in women with unexplained

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 GYNE – ENDOMETRIOSIS AND ADENOMYOSIS 3I(2017)

infertility, has been found to be beneficial in women with Diagnostic Tools:

endometriosis. Sensitivity Specificity
Ultrasound 53-89% 50-89%
MRI 88-93% 66-91%

Management:
 NO satisfactory medical management
o GnRH agonist
o Cyclic hormones
o Prostaglandin synthetase
 Hysterectomy is the definitive treatment
o Factors to consider:
 Age
 Parity
 Reproductive plans
 Uterine size
 Presence of associated pelvic pathology

ADENOMYOSIS
 Often referred as endometriosis interna
 Presence of endometrial glands and stroma within the myometrium
more than one low power field (2.5 mm) from the basalis layer
endometrium
o Derived from the aberrant glands of the basalis layer of
the endometrium
QUIZ
 Endometrial gland and stroma in the myometrium. Diagnosis:
ADENOMYOSIS
 Most common site of endometriosis: OVARIES
 Theory involved with endometrial implants found in the lungs:
LYMPHATIC AND VASCULAR
 Preferred treatment for patients with endometriosis with
infertility: SURGICAL
 Agent that gives rise to androgenic adverse effects: DANAZOL
 Give one classic symptom of endometriosis: CYCLIC PELVIC PAIN,
INFERTILITY
 Gold standard for the diagnosis of endometriosis: LAPAROSCOPY
 Medical treatment that causes medical menopause: GNRH
 Give one classic symptom of adenomyosis: MENORRHAGIA
 Definitive treatment for adenomyosis: HYSTERECTOMY

Pathogenesis: Unknown

Theories:
 Disruption of the of the barrier between the endometrium and
myometrium
 Trauma to the endometrial-myometrial interface

Pathologic Presentation:
 Diffuse involvement of both anterior and posterior myometrium
 Focal area of involvement or adenomyoma

Clinical Presentation:
 Over 50% are asymptomatic
 Symptomatic cases are between the ages of 35 and 50

Classic Symptoms:
 Secondary dysmenorrhea
 Menorrhagia

Pelvic Examination Findings:

 Uterus is diffusely enlarged, globular, usually 2-3 x normal size.
(more on posterior)

Diagnosis is confirmed following histologic examination of hysterectomy

specimen
GOOD LUCK AND GOD BLESS!

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