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Endometriosis & Adenomyosis: by R1 Jiratsaya Dankawna 22/07/2020
Endometriosis & Adenomyosis: by R1 Jiratsaya Dankawna 22/07/2020
& Adenomyosis
By R1 Jiratsaya Dankawna 22/07/2020
References
ENDOMETRIO
SIS
Definition
• Presence of endometrial-like tissue
(glands and/ or stroma) outside the
uterus
• Prevalence 3% to 43% in
asymptomatic women up to 50% in
unexplained fertility patients
• Retrograde menstruation
and implantation
• Coelomic metaplasia
ALLPPT.com
Berek & Novak’s Gynecology. 16th edition. 2019.
Petra A.B., et al. Molecular and Cellular Pathogenesis of Endometriosis. Current Women’s Health Reviews, 2018, 14, 106-16.
Genetic factor
Genetic factor
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Molecular mechanism
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Molecular mechanism
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Progesterone
17β-hydroxysteroid dehydrogenase ↑
Estradiol Estrone ↑
Normal
woman
PGE2 ↓
Estrogen production ↓
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Progesterone ↓ Progesterone resistance
17β-hydroxysteroid dehydrogenase ↓
Estradiol ↑ Estrone ↓
Woman
With Endometriosis
PGE2 ↑
Estrogen production ↑
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Epigenetic changes
MCP-1,RANTES
VEGF,MDGF,Fibronectin
IL-1, IL-8
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Mechanism of infertility
The pain associated with endometriosis has been attributed
to three primary mechanisms.
The direct and indirect effects of focal bleeding from endometriotic implants
Contents
The action of inflammatory cytokines in the peritoneal cavity
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Mechanism of infertility
Between 20% - 40% of infertile women have disease
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Dysmenorrhea
Signs
Cyclic pelvic pain
And
Symptoms
Dyspareunia
Intestinal complaints
Infertility
Mass
Vaginal examination
Infiltration or nodules of the vagina,
Uterosacral ligaments, pouch of Douglas
Deeply infiltrating endometriosis : Particular form of endometriosis that penetrate >5 mm.
under the peritoneal surface
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
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MRI
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Lapa iopsy
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Medical technologies
in the diagnosis
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
Surgical diagnosis
The classic peritoneal implant
American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997; 67:817-821
Classification and staging systems (ASRM 1996)
American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997; 67:817-821
Deep Infiltrating
Endometriosis
Johnson NP, et al. World Endometriosis Society consensus on the classification of endometriosis. Human Reproduction, Vol.32, No.2pp. 315-324, 2017.
Berek & Novak’s Gynecology. 16th edition. 2019.
Transvaginal sonography
Compared to laparoscopy, transvaginal ultrasound has no value in diagnosing
peritoneal endometriosis, but it is useful in making or excluding the diagnosis of an
ovarian endometrioma
Clinical gynecologic endocrinology and infertility/ Marc A. Fritz, Leon Speroff. 8 th edition. 2011.
MRI
MRI has good sensitivity and specificity for the diagnosis of deep
endometriosis and endometriomas
Clinicians should be aware that the usefulness of magnetic resonance
imaging to diagnose peritoneal endometriosis is not well established
(Stratton, et al., 2003)
• Empirical treatment
• Medical treatment
• Surgical treatment
• Pre or postoperative medical
treatment
• Non-medical treatment
Side effect : Nausea, weight gain, fluid retention, breast tenderness, irregular bleeding, depression
at higher dose resulting in spinal bone mineral depletion
Side effect : Bone mineral depletion, hot flashes, progressive vaginal dryness, decrease libido, depression, irritability, fatigue,
headache, changes in skin texture,
Side effect : Significant bone loss with prolong use, cannot be used alone in premenopausal causing development of multiple
ovarian cyst
ESHRE Endometriosis Guideline Development Group, 2013.
Treatment of endometriosis associated pain
Medication Leve Side effect Cost
l
1) Progestagen A Weight gain, spotting Dienogest
- Oral progestin (MPA, META,Dienogest) 2,000B/Mo
- DMPA (IM) Reversible bone marrow density 14B/3Mo
- LNG – IUD Suitable for recto-vaginal DIE Less side effect 7,000/5Y
Signs
• Uterus typically diffusely enlarge
• Usually less than 14 cm in size
• Often soft and tender, particularly at the
time of menses.
• Focal adenomyosis
Ectopic growth of the endometrium into the myometrium with focal widening of
endometrial myometrial junctional zone can be found with pelvic or ovarian
endometrioma
Diagnosis
• Adenomyosis is clinical diagnosis.
• Definitive diagnosis can only be made histologically
• Imaging studies including pelvic ultrasound or MRI are not
definitive
• Transvaginal ultrasound : accuracy rate 68%-86%
• Accuracy decrease in coexist fibroids, focal adenomyosis