Endometriosis and Adenomyosis Quiz

Endometriosis

• Endometriosis is the presence of tissue similar to normal endometrium, in structure and function, outside the uterine cavity.
• Adenomyosis is a type of endometriosis where endometrial tissue grows within the uterine muscle wall.
• True Endometriosis differs from Adenomyosis in location, affecting tissues beyond the uterine wall.

Adenomyosis

• Etiology of adenomyosis includes repeated pregnancies, vigorous curettage, and hormonal imbalance.
• Pathological characteristics include symmetrical uterine enlargement, which may be localized or diffuse. The uterine tissue displays endometrial glands and stroma surrounded by muscle fibers.
• Clinical characteristics include: end of reproductive life, multiparous, asymptomatic, menorrhagia (excessive bleeding during menstruation, possibly due to uterine enlargement and increased blood supply), and impaired uterine contractility. Dysmenorrhea (painful menstruation) and dyspareunia (painful sexual intercourse) are also possible.
• Myomas (uterine fibroids) differ from adenomyosis as fibroids seldom enlarge the uterus to over 12-14 weeks gestation.
• Treatment can include Total Abdominal Hysterectomy (TAH).

Endometriosis--Pathology

• Macroscopic findings include: small black dots ("powder burn"), large cystic masses ("chocolate cysts"), diverse lesions including black, dark-brown, bluish-puckered lesions and nodules. Atypical lesions are also present, including red implants (petechial, vesicular, polypoid), red-flame-like implants, and serous or clear vesicles. White plaques and scarring may also be present.

• Microscopic examination reveals endometrial glands and stroma, with evidence of bleeding.

Endometriosis-Diagnosis

• Symptomatology: is an initial diagnostic guide.
• Definitive diagnosis: is obtained by laparoscopy and histology (tissue examination).
• Laparoscopy, while providing high diagnostic specificity and sensitivity, requires accurate timing in the menstrual cycle to ensure sufficient evidence and can vary in interpretation when used in conjunction with classification systems (which can be subjective and poorly correlated with the pain symptoms).
• CA 125 levels may be elevated (but not considered a reliable diagnostic tool).

Endometriosis-Histology

• Determining the necessity of histology can be controversial. A positive histology confirms the presence, but negative histology alone does not exclude the possibility.
• Ideally, histological confirmation of at least one lesion is necessary, especially for endometriomas larger than 3 cm or for deep infiltrating disease needing further histology.

Endometriosis & Infertility

• Endometriosis presence correlates with infertility rates (15% of infertile women and 40-60% of affected individuals).
• Mechanisms of infertility associated with endometriosis include adhesions, reduced tubal motility, disturbed folliculogenesis and corpus luteum function, and increased inflammatory macrophages. Dyspareunia (painful sex), and increased prostaglandins also are present.

Endometriosis - Treatment

• Treatment decisions depend on severity of symptoms, patient age, and fertility expectations.
• Types of treatment include expectant management, surgical interventions (radical and conservative), and medical interventions.

Endometriosis-Medical Rx

• Medical treatment for endometriosis often involves drugs inducing remission during pregnancy (pseudopregnancy) and those inducing remission after menopause (pseudomenopause), as these periods often induce remission, often due to hormone changes.

• Hormone-based therapies (androgens, combined pills, progestins, danazol, gestrinone, GnRH agonists, and aromatase inhibitors) are often prescribed to manage endometriosis.

• Danazol: a synthetic androgen, acts by binding to sex hormone-binding globulin (SHBG), increasing free testosterone. It also prevents the monthly surge of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), inhibiting ovarian steroidogenesis (estrogen and androgen production). However, it's associated with various side effects, such as weight gain, fluid retention, breast reduction, facial hair growth, emotional lability, fatigue, oily skin, atrophic vagina, muscle cramps, deepening voice, increased cholesterol and decreased HDL. It is usually administered for 6 to 9 months at a dose of 200 mg twice daily, but has specific contraindications, such as pregnancy, severe hepatic, cardiac or renal diseases, thromboembolism, porphyria, and androgen-dependent tumours.

• Gestrinone: is a trienic-19-norsteroid inhibiting the mid-cycle surge of FSH and LH, having similar side effects as danazol but with a longer half-life (longer duration of effect, requiring a lower frequency of administration). Its typical dosage is between 2.5 and 5 mg twice weekly.

• GnRH agonists: These cause menopausal symptoms, breakthrough bleeding, and bone loss.

• Aromatase inhibitors: (e.g., anastrozole, letrozole) work to decrease both peripheral and local estradiol production. This may be a better choice than GnRH agonists for reducing estrogen-driven endometriosis, often administered with ovarian suppression.

Endometriosis--Surgical Rx

• Radical treatment involves a total abdominal hysterectomy (TAH) and removal of as much endometriosis as feasible, along with bilateral oophorectomy (removal of the ovaries).
• Conservative treatment approaches include dividing adhesions, conducting tuboplasty (reconstructing fallopian tubes), presacral neurectomy (nerve ablation near the sacrum), and laser uterine nerve ablation.

Endometriosis--Pain

• Management of pain associated with endometriosis may involve empirical treatment (without definite diagnosis, using appropriate analgesics, progestins, and combined oral contraceptives) prior to definitive diagnosis.
• Effectiveness of NSAIDS is inconsistent.
• Suppressing ovarian function for six months sometimes reduces pain, but symptom recurrence is common. Some studies show aromatase inhibitors may be effective. LNG-IUS (levonorgestrel-releasing intrauterine system) is also used for reducing pain.

Endometriosis--Assisted Reproduction

• IUI (Intrauterine Insemination) may improve fertility in cases of minimal/mild endometriosis.
• In severe cases, IVF (in-vitro fertilization) is often a primary choice, especially if other treatment options haven't worked or tubal function, male factor or other fertility-related concerns exist. GnRH agonists administered for 3-6 months prior to IVF may increase the likelihood of a successful clinical pregnancy in these cases.