Endometriosis & Adenomyosis Lecture Notes PDF

Endometriosis & Adenomyosis Dr. Iman yousif Al-Malek  Objectives Eduational Objectives: Understand the the history ,pathophysiology, varied presentation, and symptoms of endometriosis. Understand the critical need for timely diagnosis and effective intervention...

Endometriosis & Adenomyosis Dr. Iman yousif Al-Malek  Objectives Eduational Objectives: Understand the the history ,pathophysiology, varied presentation, and symptoms of endometriosis. Understand the critical need for timely diagnosis and effective intervention. Identify factors that can inform a timely and accurate diagnosis. Demonstrate an ability to recommend appropriate medical and surgical management.  Case study 1 A32-year-old women presents complaining of increasing pelvic pain with her menses over the last year since she stopped her OCPs. In particular, She has noticed more pain on her left side in the last couple of months. She denies any changes in her blabber or bowel habits, but she begun to have pain with deep penetration during intercourse. She started OCPs when she was 17 for painful irregular cycles but stopped them 1 year ago, when she got married, no history of sexual transmitted infections. On examination ,there is no abnormal discharge but her uterus is tender as well as her left adnexa with a fullness that you suspect may be a mass.On pelvic U/S she has a 5 cm cystic mass through to be an endometrioma. It persists in repeat U/S 8 weeks later & she is still symptomatic. 1. what would be the most appropriate next step in her care ? 2.what is the recommended treatment if operation was done for her through a laproscope (cystecyomy of chocalate cyst). 3.if you would to give her GnRH agonist, what are the side effects of it ?  Case study 2 A couple presents because they have been trying to conceive for 18 months.During the interview you learn that the man has fathered a child in a previous marriage and is in a good health.The women is 28 years and reported that she has had painful menses for the past 5 or 6 years. 1. If you suspect that the women has an endometriosis.What are the information in the history that increase your suspension? 2.During ex. What are the positive findings that going with endometriosis. 3.what are the percentage of endometriosis ?  Study case 3 A 46-year-old G2P2 obese women is refered from the primary care physician because of increasingly heavy &painful menses over the last 18 months. She has tried an OCPs with some improvement of her bleeding but no improvement in her pain. She reports no other history of pelvic pain or abnormal bleeding in the past. She has never had an abnormal Pap smear &states has never had any infections, Her only medical problems are her obesity , hypertension,& gastroesophagial reflex disease. On exam., you note normal external genetalia, vagina, & cervix. However, her uterus is slightly enlarged, mildly tender, and softer than you expected. She has no adnexal mass or tenderness. 1.What is the most common diagnosis? Most common investigations? 2.What are the studies you need to reach your diagnosis ? 3. What are the investigations you need if you decide to do for her Hysterectomy?  Sites of Endometriosis Women with endometriosis have patches of “normal” endometrium located outside of the uterus. The most common locations for these implants are on the: Ovary Anterior and posterior cul-de-sac Posterior broad ligament Uterosacral ligament Uterus Fallopian tube Sigmoid colon Appendix Round ligament However, endometriosis can be found virtually anywhere in the body, including sites quite remote from the pelvis, such as lung, vertebra, and skin.  What is endometriosis? Endometriosis (from endo, "inside", and metra, "womb") is a common gynecologic problem in women that is characterized by growth beyond or outside the uterus of tissue resembling endometrium, the tissue that normally lines the uterus. Endometriosis is typically seen during the reproductive years; it has been estimated that it occurs in roughly 10% to 15% of women. Its main but not universal symptom is pelvic pain in various manifestations; further, endometriosis is a common finding in women with infertility, as 30% to 40%.  Prevalence Endometriosis affects women in their reproductive years. The exact prevalence of endometriosis is not known, since many women may have the condition and have no symptoms. Endometriosis is estimated to affect over one million women (estimates range from 3% to 18% of women) in the United States. It is one of the leading causes of pelvic pain and reasons for laparoscopic surgery and hysterectomy in this country.  Prevalence While most cases of endometriosis are diagnosed in women aged around 25-35 years, endometriosis has been reported in girls as young as 11 years of age. Endometriosis is rare in postmenopausal women. Endometriosis is more commonly found in white women as compared with African American and Asian women. Studies further suggest that endometriosis is most common in taller, thin women with a low body mass index (BMI). Delaying pregnancy until an older age is also believed to increase the risk of developing endometriosis.  What causes endometriosis? * The cause of endometriosis is unknown. One theory is that an endometrial tissue is deposited in unusual locations by the* backing up of menstrual flow into the fallopian tubes & the pelvic to abdominal cavity during menstruation (termed retrograde menstruation). Another possibility is that areas* lining the pelvic organs possess primitive cells that are able to grow into other forms of tissue, such as endometrial cells. (This process is termed coelomic metaplasia). It is also likely that direct transfer of endometrial tissues *during surgery may be responsible for the endometriosis implants sometimes seen in surgical scars (for example, episiotomy or Cesarean section scars). Transfer of endometrial cells via the bloodstream or lymphatic system is the most likely explanation for the rare cases of endometriosis that develop in the lung & brain and other organs distant from the pelvis. Finally, some studies have shown alternations in the* immune response &genetic in women with endometriosis, which may affect the body's natural ability to recognize and destroy any misdirected growth of endometrial tissue.  Symptoms A major symptom of endometriosis is severe recurring pelvic pain. The amount of pain a woman feels is not necessarily related to the extent or stage (1 through 4) of endometriosis. Some women will have little or no pain despite having extensive endometriosis.On the other hand, women may have severe pain even though they have only a few small areas of endometriosis. Symptoms of endometriosic-related pain may include: Dysmenorrhea - Painful, sometimes disabling menstrual cramps; pain may get worse over time (progressive pain) also lower back pains linked to the pelvis. Chronic pelvic pain - typically accompanied by lower back pain and/or abdominal pain. Dyspareunia - Painful sex/deep dyspareunea. Dysuria - Urinary urgency, frequency, and sometimes painful voiding.  Infertility Many women with infertility have endometriosis. As endometriosis can lead to anatomical distortions and adhesions. It has been suggested that endometriotic lesions release factors which are detrimental to gametes or embryos, or, alternatively, endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon; endometriosis-associated infertility. *In general the symptom depend on the site of endometriosis.  Other symptoms may be present, including: Nausea, vomiting, and/or diarrhea - particularly just prior or during the period. Frequent menses flow or short menstrual cycle. Heavy and/or long menstrual periods. Some women may also suffer mood swings and fatigue. In addition, women who are diagnosed with endometriosis may have gastrointestinal symptoms that may mimic irritable bowel syndrome. *Patients who rupture an endometriotic cyst (chocolate cyst) may present with an acute abdomen as a medical emergency.  Diagnosis History & Examination Abd. & Vaginal) Investigations: CBC, Ca 125 ( non- spesific) Transvaginal US ( Chocolate Cyst). MRI (for Cyst & Adhesion) Diagnostic laparoscopy &Theraputic Lap. Definitive diagnosis = laparoscope + biopsy (Endometriosis) Definitive diagnosis = Hysterectomy+ biopsy (Adenomyosis) Lap. Finding : - matchstick (discrete endometrium lesion ) - adhesion - endometrioma  Treatments While there is no cure for endometriosis, in many patients menopause (natural or surgical) will abate the process. In patients in the reproductive years, endometriosis is simply managed: the goal is: *To provide pain relief, * To restrict progression of the process, and * To relieve infertility if that should be an issue. *In younger women with unfulfilled reproductive potential, surgical treatment tends to be conservative, with the goal of removing endometrial tissue and preserving the ovaries without damaging normal tissue. * In women who do not have need to maintain their reproductive potential, hysterectomy and/or removal of the ovaries may be an option; however, this will not  Treatments In general, patients are diagnosed with endometriosis at time of surgery, at which time ablative steps can be taken. Further steps depend on circumstances: patients without infertility can be managed with: *Hormonal medication that suppress the natural cycle and pain medication, while infertile patients may be treated * Expectantly after surgery, *with fertility medication, or with IVF. Sonography is a method to monitor recurrence of endometriomas during treatments. It is suggested, but unproven, that pregnancy & childbirth can cease the growth of endometriosis. Nevertheless, after the pregnancy, there is no  Treament :either surgery or medication. Surgery: Although medicine is extensively used for this condition, the most effective treatment is surgical : The approach can be either by laparoscopy or laparotomy. Conservative therapy is usually applied in women where the reproductive potential needs to be maintained and consists of removal or ablation of endometriosis, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible Laparoscopic removal or ablation of endometriosis in minimal or mild endometriosis has been shown to be equal or better then expectant management, medical therapy, or surgery via laparotomy.  2nd type of surgery Radical therapy in endometriosis removes the uterus (Hysterectomy) and tubes and ovaries (bilateral salpingo- oophorectomy). Modifications of this approach involve preserving a healthy appearing ovary, however, this will increase the risk of recurrence. Radical surgery is generally reserved for women with chronic pelvic pain that is disabling and treatment-resistant. Not all patients with radical sugery will become pain-free. For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. However, strong clinical evidence showed that presacral neurectomy is more effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the pain extends to the left and right lower quadrants of the abdomen. This is due to the fact that the nerves to be transected in the procedure are innervating the central or the midline region in the female pelvis. Furthermore, women who had presacral neurectomy have higher prevalence of chronic constipation not responding to medication (injury to the parasympathetic nerve).  Types of medication Treatments for endometriosis in women who do not wish to become pregnant include: Medication *NSAIDs not only reduce pain but also reduce menstrual flow. They are commonly used in conjunction with other therapy. For severe cases narcotic prescription drugs may be used. *Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Progestins are chemical variants of natural progesterone. Vissane 2 mg (Dienogest) 28 tab. give cont. for 3 – 9 month.  Types of medication *Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach. *Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism. *Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in down regulation, inducing a profound hypoestrogenism by decreasing FSH and LH levels. While quite effective, they induce unpleasant  eg. Lupron depot shot is a GnRH agonist and is used to lower the homone levels in the woman's body to prevent or reduce growth of endometriosis. The injection is given in 2 different doses a once a month for 3 months, shot with the dosage of (11.25mg) or a once a month for 6 month shot with the dosage of (3.75mg). *Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis..  Adenomyosis Adenomyosis uteri is defined by the presence ofendometrium within the myometrium. Adenomyosis uteri can involve the whole muscle thickness down to the serosa and can be either‘focal’ or ‘diffuse’. In diffuse adenomyosis uteri, the uterus becomes enlarged and globular. Associated pathology: Up to 80% of women with adenomyosis also have other lesions, the most frequent being leiomyomas. Endometrial polyps, hyperplasia (with and without atypia) and adenocarcinoma are more frequent in women with adenomyosis.  Prevalence & Symptoms The majority of cases are reported in women aged 40–50 years and there is a positive association with parity. Adenomyosis occurs relatively frequently in pregnancy, and was diagnosed using MRI. There is no relation to age at first childbirth and prior caesarean section The majority of cases are reported in women aged 40–50 years and there is a positive association with parity.  Symptoms Menstrual disorders: About 35% of women with adenomyosis uteri are asymptomatic. Symptomatic women mostly resent with menorrhagia (40–50%), dysmenorrhoea (10–30%) and metrorrhagia (10–12%,) and occasionally, dyspareunia. Menorrhagia or Heavy menstrual bleeding may be due to dysfunctional contractility of the myometrium. Mefenamic acid administration can reduce blood loss, suggesting that prostaglandins may be involved. Other factors that may be involved are anovulation or endometrial hyperplasia. The extent and spread of adenomyosis uteri may correlate with pelvic pain and dysmenorrhea and, to a lesser degree, with menorrhagia and dyspareunia.  Treatment of Adenomyosis Different surgical and medical modalities of treatment: Medical: Non-hormonal therapy, including mefenamic and Tranexamic acid, may be effective for the symptomatic relief of menorrhagia associated with uterine adenomyosis Low-dose, continuous combined oral contraceptives wit withdrawal bleeds every 4–6 months may be effective in relieving menorrhagia and dysmenorrhoea.  Medical treatment of Adenomyosis (cont.) GnRH analogues have also been used in the treatment of adenomyosis uteri.They reduce uterine volume and result in symptomatic relief but their use is limited because of skeletal and general swide effects. The use of danazol has largely been superseded because of its side- effects. A more recently-developed danazol-loaded intrauterine device is used. The levonorgestrel-releasing intrauterine system has also been successfully used for adenomyosis-associated menorrhagia ( Mirena). Mifepristone (RU486) has been used for the treatment of endometriosis. Long-term, low-dose mifepristone causes anovulation, a reduction in painful symptoms and improved endometriosis. GnRH agonist in a woman with severe symptomatic uterine adenomyosis.  Surgical treatment of Adenomyosis Laparoscopic myometrial electrocoagulation induces localised coagulation and necrosis ofadenomyosis uteri. Endomyometrial ablation or resection may be an option for women with superficial disease complaining of menorrhagia but, clearly, desire for a future pregnancy is a contraindication. Reduction of the uterine blood flow by uterine artery embolisation has been shown to reduce the symptoms associated with adenomyosis uteri and to improve the quality of life. Furthermore, there is a risk of emergency hysterectomy for uncon- trollable bleeding during the procedure, as well as a high incidence of adhesion formation following the procedure. Although not recommended, this technique may suited for women more than 40 years of age who have completed their families. Obst. & Gyne. Conference 27 April/ 2016