Endometriosis Adenomyosis

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Endometriosis

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Definition:
Abnormal growth of endometrial tissue outside the uterine cavity.

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Incidence and Prevalence:

Increase significantly Range from 1 50% General population:1 2% Infertile women:30 50% Occurs primarily in women in 25 45s

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Pathogenesis:
Implantation Theory Retrograde Menustration Theory Sampson1921 Lymphatic and Vascular Dissemination Theory Javert1952 Coelomic Theory Meyer Genetic Theory Immune System Dysfunctionimmunologic theory
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Genetic factors
Familial clustering of endometriosis is a common clinical observation. In families with endometriosisthe disease is often confined to the maternal lineand is 7 times more common in first-degree relatives than in the general population. In future studiesevaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.
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Immunologic Theory

1)

Lose control of immunologic balance Both cellular immunity and humoral immunity change.
Macrophage release IL1IL6TNFEGF FGF etc. stimulate TB lymphocyte proliferation and activation Activity of killer cellNK cell and T cell Produce antiendometrium antibody Abnormal expression of CAMscell adhesion molecules
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2) 3) 4)

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 The pathogenesis is unclear.

multifactor

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Pathology macroscopic appearance1

The commonest sites 1. Ovarychocolate cyst 2. Peritoneum of the rectovaginal culde sac of the Pouch of Douglas 3. Uterosacral ligaments 4. Sigmoid colon 5. Broad ligament
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This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst.
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Pathology macroscopic appearance 2

1. 2. 3. 4. 5. 6. Less common sites Cervix Round ligament Urinary systembladderureter Umbilicus Appendix Laparotomy scars
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Multiple appearances of endometriosis implants

Brownishdiscolored peritoneum Superficial peritoneal ecchymosis Raisedreddishsuperficial nodules Reddishblue invasive nodules Fibroticwhitish nodules Raisedglossytranslucent blobs Patchywhite opacified peritoneum Reddish or bluish ovarian cysts
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Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas. Such areas of endometriosis can be seen and obliterated by cauterization via laparoscopy.
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Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.
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Pathology microscopic appearance

Histomorphologically similar to eutopic endometrium Ectopic endometrium endometrium Eutopic
Four major components endometrial glands endometrial stroma fibrosis hemorrhage
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Clinical Manifestation

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Symptoms
Pain progressive dysmenorrhea dyspareunia painful defecation Menstrual disturbance infertility
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dysmenorrhea dyspareunia

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Signs
Enlargement of the ovariesfixed Fixed retroversion of the uterus Tender nodules within the pelvis
Cannot be diagnosed by PV alone. Should always be considered when patients have symptoms referable to the pelvic cavity.
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 Very variable Vary with the focus location Often bear no relation to the extent of the disease Quite often deposits are found incidentally in women who have no symptoms. 25% have no symptoms

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Diagnosis
History PV examination Laparoscopygolden standard UltrasonographyBtype ultrasound CA125 200U/mlnormal value 35U/ml Antiendometrium antibody+
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Staging systems
In the AFS-r1985staging systempoints are assigned for severity of endometriosis based on the size and depth of the implant and for the severity of adhesions. The points are summed and the patients are assigned to one to four stages Stage I minimal disease 15 points Stage II mild disease 615 points Stage III moderate disease1640 points Stage IV severe disease 40 points
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Differential diagnosis
Malignant ovary tumours
Pelvic inflammatory masses

Adenomyosis

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Treatment

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Expectant therapy
Indicationswith very limited disease
whose symptoms are minimal or nonexistent

If trying to get pregnantthe best way is to accept laparoscopic therapy as early as possible.

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Medical therapy
Indicationschronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation
Hormoneinhibition therapy

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Drugs
Danazolpseudomenopause therapy Gestrinone GnRH amedical oophorectomy add back therapy Mifepristone RU486 Progestogenspseudopregnancy therapy
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Surgical therapy1
Indications1adnexal mass 2pelvic pain 3infertility Approaches (1) trans abdominal (2) laparoscopic
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Surgical therapy2
Methods Conservative surgery 1) preserve the fecundity 2) preserve the ovarian function Definitive surgery hysterectomy + salpingooophorectomy
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Combination
Threestep

medicalsurgical treatment
surgery

medical therapy

second looklaparoscopy
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 It is important to individualize the choice of therapy.

Therapy must be tailored to the degree of symptomatology the patients age her desire to maintain fertility
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Prognosis
With proper treatmentthe prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis. In most caseshormonal therapy is temporarily effective in controlling symptoms and arresting growth but is generally less effective than surgery in increasing fertility. The recurrent rate is very high.
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Prevention
Avoid possible augmentation of menstrual reflux.
Taking oral contraceptive is recommended. Isolation and irrigation of the operative site.

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Critical points1
The pathogenesis is poorly understoodbut emerging evidence supports the causative role of retrograde menstruation and implantation of endometrial tissue. Endometriosis is a common in women with pelvic pain or infertility.

Laparoscopy is the optimal technique to diagnose pelvic endometriosis.

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Critical points2
In most casessurgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility. Alternativelymedical therapy with progestins danazolgestrinone or GnRH-a will ameliorate pelvic painbut they do not enhance fertility. Endometriosis is a recurrent diseaseand definitive treatment with removal of pelvic organs may be necessary.
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Adenomyosis

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Definition
A benign uterine condition in which endometrial glands and stroma are found deep in the myometrium.

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Etiology
Basal endometrial hyperplasia invading a hyperplastic myometrial stroma. Four primary theories Heredity Trauma Hyperestrogenemia Viral transmission
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Pathology gross appearance

Usually hyperemic with thickened walls The foci are frequently scattered diffusely throughout the myometrium. Occasionallymay be more circumscribedwith the formation of a distinct nodulean adenomyoma.
Adenomyosis
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Adenomyoma
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The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis. There is also a small white leiomyoma at the lower left.
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Clinical features1
Symptomatic adenomyosis occurs primarily in parous women over the age of 40 . 30 50 Classic symptoms secondary dysmenorrhea abnormal uterine bleeding

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Clinical features2
Most common physical sign a diffusely enlarged uterus
(rarely exceeds 12 weeks gestation in size)

particularly tender during menstruation

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Diagnosis
History Pelvic examinations Ultrasonography Serum markersCA-125

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Treatment
Hormone therapy Hysterectomythe only uniformly successful treatment for adenomyosis is necessary.

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