Harvey's Garden

Endometriosis

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aliasesAdenomyosis

3 min read

Epidemiology

Etiology

Pathophysiology

  • In endometriosis, endometrial tissue occurs outside of the uterus.
    • It’s adenomyosis if in uterus.
  • Common locations of endometriotic implants include:
    • Pelvic organs
      • Ovaries: most common site; often affected bilaterally
      • Rectouterine pouch
      • Fallopian tubes
      • Bladder
      • Cervix
    • Peritoneum
    • Extrapelvic organs (e.g., lung or diaphragm): less commonly affected
  • Regardless of where the endometrial tissue is located, it reacts to the hormone cycle in much the same way as the endometrium and proliferates under the influence of estrogen.
  • Endometriotic implants result in:
    • ↑ Production of inflammatory and pain mediators
    • Anatomical changes (e.g., pelvic adhesions) → infertility

Clinical features

  • Classic Triad (“3 Ds”):
    • Dysmenorrhea: Cyclic pelvic pain starting 1-2 days before menses.
    • Deep dyspareunia: Pain with deep penetration.
    • Dyschezia: Painful defecation (worse during menses).
  • Additional symptoms: Chronic pelvic pain (>6 mos), infertility, abnormal uterine bleeding (AUB), cyclic hematuria/dysuria.
  • Physical Exam:
    • Fixed, immobile, retroverted uterus.
    • Tender nodularity in uterosacral ligaments or posterior cul-de-sac.
    • Adnexal mass (endometrioma).
    • Cervical motion tenderness (CMT) or lateral displacement of cervix. c

Diagnostics

  • Initial Test: Transvaginal Ultrasound (TVUS).
    • Evaluates for endometrioma (“ground-glass” appearance, homogenous low-level echoes).
    • Normal TVUS does not rule out superficial peritoneal endometriosis.
  • Confirmatory / Gold Standard: Laparoscopy w/ biopsy.
    • Visualizes “powder-burn” lesions (blue-black/brown spots), fibrous adhesions, or “chocolate cysts”.
    • Histology confirms ≥2 features: Endometrial glands, stroma, hemosiderin-laden macrophages.
  • Key Labs: CA-125 may be ↑ (nonspecific, used only for monitoring treatment/recurrence, not for diagnosis).

Pathology

  • Normal endometrial glands
  • Normal endometrial stroma
  • Preponderance of hemosiderin laden macrophages due to cyclic hemorrhages into endometriomas

Differential diagnosis

Adenomyosis

Tip

  • Endometriosis: fixed, immobile uterus (due to pelvic adhesion)
  • Adenomyosis: enlarged, boggy, tender uterus
  • Definition: benign disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
  • Epidemiology: peak incidence at 35–50 years
  • Clinical features
    • May be asymptomatic
    • Dysmenorrhea
    • Abnormal uterine bleeding
    • Chronic pelvic pain, aggravated during menses
    • Globular, uniformly enlarged uterus that is soft but tender on palpation
  • Diagnostics
    • Diagnosis is clinical and may be supported by transvaginal ultrasound and MRI findings
      • Asymmetric myometrial wall thickening
      • Myometrial cysts

Pathology

Macroscopic findings

  • Ovaries
    • Gunshot lesions or powder-burn lesions
      • Black, yellow-brown, or bluish nodules or cystic structures
      • Seen on the serosal surfaces of the ovaries and peritoneum
    • Ovarian endometriomas or chocolate cysts: cyst-like structures that contain blood, fluid, and menstrual debris

Treatment

Endometriosis

  • Asymptomatic / Incidental Finding: No treatment needed.
  • First-line (Pain Control & Contraception Desired):
    • NSAIDs + Combined Oral Contraceptives (COCPs) OR Progestin-only agents (e.g., levonorgestrel IUD, DMPA).
  • Second-line (Refractory to COCPs/NSAIDs):
    • GnRH agonists (e.g., leuprolide) or GnRH antagonists (e.g., elagolix) + “add-back” therapy (low-dose estrogen/progestin) to prevent bone mineral density loss and vasomotor symptoms.
  • Surgical Management:
    • Indications: Refractory medical management, contraindication to meds, or medication-resistant infertility. c
    • Conservative Surgery: Laparoscopic excision/ablation of implants + cystectomy for endometriomas (preserves fertility).
    • Definitive Surgery: Total hysterectomy + bilateral salpingo-oophorectomy (BSO) (completed childbearing).
  • Infertility Management:
    • Medical therapy (COCPs, GnRH agonists) does NOT improve fertility.
    • First step: Laparoscopic resection of implants to restore normal pelvic anatomy.
    • Next step: Assisted Reproductive Technology (ART) / IVF if surgery fails or maternal age is advanced.

Adenomyosis

  • Medical: Primarily aimed at symptom control (reducing bleeding/pain).
    • Levonorgestrel-releasing IUD (Mirena) is highly effective.
    • Combined OCPs or progestin-only therapy can also be used.
  • Surgical:
    • Hysterectomy is the only definitive treatment.
    • Uterine artery embolization is an alternative for those wishing to avoid hysterectomy.

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