ENDOMETRIOSIS AND

ADENOMYOSIS
 What is endometriosis?

• Presence of functioning endometrial

tissue outside the uterine cavity ie
other than uterine mucosa (ectopic
sites)

• Composed of endometrial glands

surrounded by endometrial stroma
• Benign condition but behaves as malignant

• It can grow, invade normal surrounding

tissue and can be present at different sites

• Responds to hormones and drugs

Classified as

• Interna (Adenomyosis)
• Externa
 Incidence
• Occurs in 7-10 % of reproductive age women
• Incidence is increasing
• More among infertile women (30-40%)
 Etiology
• Unknown

• No single theory can explain the location of

endometriosis in all cases
Menstrual regurgitation and Transplantation theory (Sampson’s theory )

• Retrograde menstrual flow transport

desquamated endometrial fragments through
fallopian tubes during menstruation into the
peritoneal cavity

• Viable cells implant and begin to grow and

invade the tissue
Conditions where ↑ retrograde mens causing
endometriosis more likely

• obstruction of outflow tract eg imperforate

hymen, transverse vaginal septum

• Women with shorter intervals between

menstruation and longer duration of menses
• Explains presence of endometriosis in ovary,
tube, POD etc but not in distant sites
Coelomic metaplasia theory (Meyer and Ivanoff)

• Mullerian tissue and the peritoneum is developed from

celomic epithelium

• Chronic irritation of pelvic peritoneum by the

menstrual blood can cause celomic metaplasia and
differentiation of peritoneal epithelium into the
endometrial epithelium

• Explains endometriosis of umbilicus, abdominal

viscera, rectovaginal septum
 Immunological and Genetic theory

• Retrograde blood flow is likely to occur during

menstruation but not all the women develop
this condition
• Endometriosis develops in women with
immunologic and genetic susceptibility
• Risk is increased 6-7 times if first degree
relative is affected
 Direct implantation, Lymphatic and Vascular
theory
• Direct implantation of endometrial tissue may
occur during surgeries like C section,
myomectomy or hysterotomy

• Endometrial tissue may metastasize through

lymphatic and vascular channel

• Explains the endometriosis at distant sites

 Rare sites
• Abdominal scars after Cesarean or
hysterotomy or myomectomy
• Umbilicus
• Episiotomy scar
• Lungs/pleura
• Ureter/urinary bladder
• Nasal mucosa
 Pathology

• Cyclical growth and shedding of endometrium occurs

under the hormonal influence as in menstrual cycle

• Cyclical bleeding from the endometriotic deposits

causes local inflammatory reaction, fibrous adhesion
formation

• Periodical shedding and bleeding in a closed space

deep in the ovary will result in encysted cyst which
may enlarge or rupture in due course of time
• The blood in the encysted cyst becomes chocolate
colored when serum gets absorbed known as
chocolate cyst (endometriotic cyst, endometrioma)

• Endometrial tissue deep within the myometrium wall

termed as adenomyosis
 Naked eye appearance

• Varies from few lesions to massive endometriotic cyst

distorting pelvic cavity, tubo-ovarian anatomy and
extensive adhesions involving bowel, bladder and
ureter

• The pelvic endometriosis appear as black

dots/deposits powder burn type or red flame shaped
lesions

• The ovaries are generally involved bilaterally

 Histopathology

• Presence of endometrial tissue, glands and stroma

• Lining of the endometriotic cyst may be flattened or

absent

• Phagocytic cells laden with blood pigment

(hemosiderin) may be present beside the lining
epithelium
 Clinical features

• Age – reproductive age group between 30-45 yrs

• Nulliparous or having one or 2 children with long gap of

last child birth or deferring pregnancy for long interval

• Family history

• Upper social class

• H/O outflow tract obstruction

 Symptoms
• Asymptomatic – 25-30%

• PAIN
Dysmenorrhea- begins before and continues during the mens

Abdominal pain- constant dragging or aching pain, aggravated by

mens / Chronic pelvic pain

Acute pain due to rupture of endometriotic cyst

No correlation between pain and severity of

disease
 Symptoms…

• Menorrhagia- common with both endometriosis and

adenomyosis

• Dyspareunia-deposits in POD, uterosacral ligaments

• Infertility- 30-40% remain infertile

 Site specific symptoms

• Urinary frequency and dysuria, hematuria during

menstruation

• Painful defecation (dyschezia)

• Diarrhea, malena around the time of menstruation

due to involvement of sigmoid colon, rectum

• Cyclical pain and swelling over the scar, umbilicus etc

 Examination findings

P/A – Normal OR
• Pelvic mass (endometriotic cyst, tubo-ovarian mass)

• Mass with restricted mobility

• Tender

• P/S – bluish spots in POD, cervix, vagina

 Examination findings

• P/V- No abnormality OR

• Uerus may be normal or slightly enlarged, retroverted,

restricted mobilility and tender

• Nodular/ irregular feeling POD, tender

• Cervical motion tenderness

• Adnexal mass/bilateral, tender, restricted mobility

 Investigations
• USG- adnexal mass, endometrioma

• CA 125

• Laparoscopy

• Endometrial biopsy

• CT / MRI/ colonoscopy/rectosigmoidoscopy/cystoscopy

• Histopathology
 Differential diagnosis
• Chronic Pelvic Inflammatory Disease

• Chronic ectopic pregnancy

• Ovarian tumor/ ovarian malignancy

• Fibroid uterus
 Diagnosis
• Clinical - classic symptoms of presentation and
examination findings are S/O endometriosis

• Laparoscopy – gold standard

• Histopathology – gold standard

 Treatment
• Expectant management

• Medical management
Non hormonal and hormonal

• Surgical management
 Expectant management
Mild disease, asymptomatic

Advised to become pregnant in women whose

family is incomplete

Infertiltity- investigation and treatment

 Non hormonal treatment

Non steroidal anti-inflammatory agents

• Ibuprofen
• Anti prostaglandin- mefenamic acid
 Hormone therapy
Estrogen and progesterone pill (COCP)
• Mechanism of action
Continuous hormone therapy will induce
pregnancy like state by endometrial
decidualization (pseudo-pregnancy state)
followed by atrophy
Absence of menstruation
 Progesterone- 6-9 months

• Oral-medroxyprogesterone acetate
• Injectible-depo provera
• IUCD-levonorgestrel (Mirena)

Mechanism of action- act as anti-estrogen

• Decidualization
• Atrophy
• Anovulation and amenorrhea
 Synthetic androgens

Danazole 600-800 mg/day, 3-6 months

• Creates hypoestrogenic state by suppressing
hypothalamus-pituitary-ovarian axis and
endometrial atrophy (menopausal like state)
• S/E-hirsutism, hoarseness of voice

Gestrinone weak androgen, long acting, 2.5 mg

twice weekly
 GnRH analogues
Continuous use will create menopause like
hypoestrogenic state with amenorrhea, no
endometrial growth

• Most costly among all drugs used

• S/E- hot flashes, osteoporosis
• Cannot use more than 6 months
 Aromatase inhibitors
• letrozole 2.5 mg, anastrozole 1 mg

• Prevents conversion of androgen into

estrogen in peripheral tissue by suppressing
peripheral aromatase activity
 Disadvantage of medical management

• No permanent cure

• Recurrence when therapy is stopped and

ovarian activity resume

• Some are costly

• Cannot give for long term

 Surgical management
Indications
• When symptoms are severe and fails to
respond to hormone therapy

• Endometriotic cysts

• Infertility due to adhesions/ endometriotic

cyst
 Conservative surgery
To preserve reproductive function, improve
symptoms by destruction of the lesions

Laparoscopy or laparotomy
• Cyst excision, ablation/ fulguration of
endometritic deposits by electric diathermy,
laser vaporisation
• Adhesiolysis
 Definitive surgery

• Total hysterectomy with B/L salpingo-

oophorectomy
Adenomyosis
 Definition
• Growth of the endometrial tissueboth gland
and stroma within the myometrium,
• Adenomysois, endometriosis and uterine
leiomyoma frequently co-exist
• Average age of symptomatic women is usually
older than 40 yrs
• Increasing parity may be a risk factor
 Aetiology
• Unknown

Risk factors
• Repeated child birth
• Vigorous curettage, repeated curettage
• Hyperestrogenic state
 Symptoms and signs
• Often asymptomatic
• Menorrhagia
• Dysmenorrhea
• Dyspareunia
• Diffusely enlarged uterus (<14cm) often
confused with fibroid
• Mobility not restricted, no adnexal pathology
• Naked eye appearance- diffuse symmetrical
enlargement
• Cut section- thickened uterine wall
(myometrium), surface rough, trabeculated,
absence of capsule, small hemorrhagic spots
• Histology-endometrial gland and stroma in the
myometrium
Adenomyosis and fibroid
 Diagnosis
• Clinical
• Ultrasound-heterogenous echogenisity, small
cystic spaces in the myometrium, increased
vascularity
• confirmed only after histopathology
• Does not respond to hormone as it is formed
by invazination of basal endometrium
 Treatment

• Depends on the pt’s age and desire for future

fertility
• Non-steroidal anti-inflammatory agents
• Oral contraceptives
• Progesteron to suppress menstruation
• Hysterectomy
 Summary
• Definition: endometriosis/adenomyosis
• Clinical features
• Aetiology
• Investigations
• Treatment
• Expectant
• Medical
• Surgical
Thank you