Endometriosis and Adenomyosis

Question 1

Most common sites of endometriomas?

Answer 1

Ovary and pelvic peritoneum (anterior and posterior cul de sacs)

Question 2

Three theories of endometriosis origin?

Answer 2

1 is Altered immune system that is less likely to recognize and attack endometrial implants

1) Lymphatic system transfer of endometrial tissue
2) Metaplastic transformation of multi-potent cells in peritoneal tissue
3) Retrograde menstruation theory

Question 3

Does severity of symptoms correlate with the amount of endometriosis?

Answer 3

No, not necessarily

Question 4

Diagnosis of endometriosis?

Answer 4

Surgical confirmation

Question 5

Risk factors of endometriosis?

Answer 5

First degree relatives

Autoimmune inflammatory disorders

Question 6

Symptoms?

Answer 6

• Cyclic pelvic pain that starts 1-2 wks before menses and peaks 1-2 days before period starts
• Dyspareunia
• Dysmenorrhea
• Abnormal bleeding
• Bowel and bladder symptoms
• Subfertility

Question 7

Physical exam findings?

Answer 7

Uterosacral nodularity
Fixed retroverted uterus
Fixed adnexal mass when ovary is involved

Question 8

Management?

Answer 8

Empiric medical therapy rather than surgery (though this wouldn’t give the definitive diagnosis)

Moderate: pseudopregnancy

• NSAIDs
• Estrogen-progestin contraceptives (pill patch ring)
• Progestins for menstrual suppression (injectable, oral, intrauterine)

Moderate to severe: pseudomenopause

• Danazol
• GnRH agonists like leuprolide acetate and nafarelin (suppress FSH and LH)
• Aromatase inhibitors like anastrozole and letrozole are OFF LABEL

Severe: do surgery

Question 9

Side effects of the GnRH agonists?

Answer 9

Estrogen deficiency and menopause sx

Question 10

Side effects of the androgen derivatives (eg. danazol)?

Answer 10

Androgen related and anabolic like acne, oily skin, weight gain, edema, hirsutism, voice deepening

Question 11

Add-back therapy?

Answer 11

Add a small amount of progestin without estrogen to the GnRH agonist to HAVE those GnRH agonist benefits while minimizing the effects of estrogen deficiency.

This way, treatment can be for longer up to 1 year.

Question 12

Definitive treatment?

Answer 12

TAH BSO with lysis of adhesions and removal of any visible endometriosis lesions.

Question 13

Current theory of adenomyosis?

Answer 13

1) Hyperplasia of the basal is layer of the endometrium
2) Metaplastic transformation of mullein rest cells of the myometrium

Fact is that the endometrium and myometrium barrier is broken and the endometrial cells can invade.

Question 14

Adenomyosis does what to uterus?

Answer 14

Soft and boggy. Diffusely enlarged globular uterus.

Hypertrophy and hyperplasia causes diffuse enlargement, usually most prominent in fundus and posterior uterine wall.

Question 15

Treating adenomyosis?

Answer 15

1 temporary is levonorgetrel IUD

NSAIDs, estrogen-progestin contraceptives (but don’t work as well as they do for endometriosis), progestins

Hysterectomy

Question 16

Histo of adenomyoma?

Answer 16

Not encapsulated like a leiomyoma

Question 17

Risk factors?

Answer 17

Adenomyosis, endometriosis, uterine fibroids often coexist.

Question 18

Clinical symptoms of adenomyosis?

Answer 18

Menorrhagia (50%)
Secondary dysmenorrhea (30%)
Both (20%)

Question 19

How do you diagnose adenomyosis?

Answer 19

TSH, pelvic ultrasound, endometrial biopsy (r/o other causes of abnormal uterine bleeding)

MRI is most accurate and should be used for a positive u/s and if you’re planning on doing a myomectomy so you can tell if its fibroids or adenomyosis.