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Endometriosis & Adenomyosis Omar Al Omari, MRCOG Obstetrician & Gynaecologist Jordan Hospital Medical Center 1

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2 Endometriosis

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

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4 Incidence and Prevalence : Increased significantly Range from 1 50% General population : 1 2% Infertile women : 30 50% Occurs primarily in women in 25 45s

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5 Pathogenesis : Implantation Theory Retrograde Menustration Theory Sampson 1921 Lymphatic and Vascular Dissemination Theory Javert 1952 Coelomic Theory Meyer Genetic Theory Immune System Dysfunction immunologic theory

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6 Genetic factors Familial clustering of endometriosis is a common clinical observation. In families with endometriosis the disease is often confined to the maternal line and is 7 times more common in first-degree relatives than in the general population. In future studies evaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.

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7 Immunologic Theory Lose control of immunologic balance Both cellular immunity and humoral immunity change. 1)Macrophage release IL1 IL6 TNF EGF FGF etc. stimulate T B lymphocyte proliferation and activation 2)Activity of killer cell NK cell and T cell 3)Produce antiendometrium antibody 4)Abnormal expression of CAMs cell adhesion molecules

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8 The pathogenesis is unclear. multifactorial

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9 Pathology macroscopic appearance 1 The commonest sites 1.Ovary chocolate cyst 2.Peritoneum of the rectovaginal culde sac of the Pouch of Douglas 3.Utero sacral ligaments 4.Sigmoid colon 5.Broad ligament

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10 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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12 Pathology macroscopic appearance 2 Less common sites 1.Cervix 2.Round ligament 3.Urinary system bladder ureter 4.Umbilicus 5.Appendix 6.Laparotomy scars

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13 Multiple appearances of endometriosis implants Brownish discolored peritoneum Superficial peritoneal ecchymosis Raised reddish superficial nodules Reddishblue invasive nodules Fibrotic whitish nodules Raised glossy translucent blobs Patchy white opacified peritoneum Reddish or bluish ovarian cysts

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14 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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15 Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.

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16 Pathology microscopic appearance Histomorphologically similar to eutopic endometrium Four major components endometrial glands endometrial stroma fibrosis hemorrhage

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17 Clinical Manifestation

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18 Symptoms Pain progressive dysmenorrhea dyspareunia painful defecation Menstrual disturbance infertility

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19 Signs Enlargement of the ovaries fixed 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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20 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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21 Diagnosis History PV examination Laparoscopy golden standard Ultrasonography Btype ultrasound CA125 200U/ml normal value 35U/ml Antiendometrium antibody +

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22 Staging systems In the AFS-r 1985 staging system points 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 1 5 points Stage II mild disease 6 15 points Stage III moderate disease 16 40 points Stage IV severe disease 40 points

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23 Differential diagnosis Malignant ovary tumours Pelvic inflammatory masses Adenomyosis

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24 Treatment

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25 Expectant therapy Indications with very limited disease whose symptoms are minimal or nonexistent If trying to get pregnant the best way is to accept laparoscopic therapy as early as possible.

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26 Medical therapy Indications chronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation Hormoneinhibition therapy

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27 Drugs Danazol pseudomenopause therapy Gestrinone GnRH a medical oophorectomy add back therapy Mifepristone RU486 Progestogens pseudopregnancy therapy

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28 Surgical therapy 1 Indications 1 adnexal mass 2 pelvic pain 3 infertility Approaches (1) trans abdominal (2) laparoscopic

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29 Surgical therapy 2 Methods Conservative surgery 1)preserve the fecundity 2)preserve the ovarian function Definitive surgery hysterectomy + salpingooophorectomy

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30 Combination medicalsurgical treatment Threestep surgery medical therapy second look laparoscopy

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31 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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32 Prognosis With proper treatment the prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis. In most cases hormonal 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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33 Prevention Avoid possible augmentation of menstrual reflux. Taking oral contraceptive is recommended. Isolation and irrigation of the operative site.

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34 Critical points 1 The pathogenesis is poorly understood but 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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35 Critical points 2 In most cases surgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility. Alternatively medical therapy with progestins danazol gestrinone or GnRH-a will ameliorate pelvic pain but they do not enhance fertility. Endometriosis is a recurrent disease and definitive treatment with removal of pelvic organs may be necessary.

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36 Adenomyosis

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

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

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39 Pathology gross appearance Usually hyperemic with thickened walls The foci are frequently scattered diffusely throughout the myometrium. Occasionally may be more circumscribed with the formation of a distinct nodule an adenomyoma.

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40 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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41 Clinical features 1 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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42 Clinical features 2 Most common physical sign a diffusely enlarged uterus (rarely exceeds 12 weeks gestation in size) particularly tender during menstruation

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43 Diagnosis History Pelvic examinations Ultrasonography Serum markers CA-125

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44 Treatment Hormone therapy Hysterectomy the only uniformly successful treatment for adenomyosis is necessary.

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Thank You 45