Endometriosis & Adenomyosis
Anna Mae Smith, MPAS, PA-C Lock Haven University Physician Assistant Program
Description of Endometriosis
presence of endometrial tissue, composed of glands and stroma, at sites outside endometrial cavity most common sites
– – – – ovary broad ligament cul-de-sac rectovaginal septum
endometrial tissue responds cyclically to estrogen
– swelling – producing local inflammation
severity of pain unrelated to extent of disease
– There may be more pain associated with active lesions in mild disease than with adhesions in severe disease
commonly occurs in women in 20’s and 30’s
– tends not to occur before menarche or after menopause
major cause of infertility
Theories for Etiology
Sampson’s theory of retrograde menstruation Halban’s lymphatic spread theory Meyer’s mullerian metaplasia theory
– metaplasia of mesothelial cells into endometrial epithelium under some unidentified influence, such as repeated inflammation
Hematogenous spread
Epidemiology
found equally among all races more likely to occur and progress in women with
– early menarche – in those with menstrual flow exceeding seven days – cycles of less than 27 days – years of menstruation uninterrupted by pregnancy – family history of endometriosis
Incidence
10-15 % of women of reproductive age 40-50 % of women undergoing surgery for evaluation of infertility average age at diagnosis is 28
History
most common symptoms
– – – – dysmenorrhea dyspareunia (especially on deep penetration) perimenstrual back pain infertility
other symptoms reported
– dyschezia – abdominal pain – irregular bleeding patterns, especially premenstrual spotting
less common symptoms
– urgency in urination – hematuria – rectal bleeding
Physical Exam Findings
may appear normal if lesions = small & few advanced disease
– cervical displacement of 1 cm or more to the left or right of midline – bimanual exam tenderness and nodularity of the uterosacral ligaments and posterior cul-desac are detected – adnexal masses that vary in size, shape, and consistency and may be asymmetric, fixed, cystic, or indurated – fixed retroversion of the uterus
Endometriosis on /in the Ovary
Forms a dark, chocolate cystic mass.
Diagnostic Tests
CA-125 elevated CBC normal ESR normal Diagnostic laparoscopy
http://medstat.med.utah.edu/kw/human_repro d/mml/hr08.html
Differential Diagnoses
chronic PID recurrent acute salpingitis hemorrhagic corpus luteum benign or malignant ovarian neoplasm ectopic pregnancy adenomyosis
Treatment Plan
psychosocial intervention medications
– – – – danazol progestogens combined Ocs gonadotropin-releasing hormone agonists (GnRH-a)
• Lupron injection qmo x 6 mos • Synarel nasal spray bid x 6 mos
surgical interventions: conservative vs. definitive
GnRH analogs
Decreases secretion of gonadotropins Major concerns are…
– – – – Cost Parenteral administration Potential for accelerated bone mineral loss Hot flashes & hypo-estrogen states
Adenomyosis
Growth of the glands & stroma within the myometrium (muscle wall) Affects the parous women over 40 y/o Etiology - downward growth of surface endometrium
Adenomyosis - S &S
Dysmenorrhea Menorrhagia Bulky, boggy, tender, uterus on exam : if menstruating, uterus may be board-like!
Treatment of Adenomyosis
Medical therapy used to treat endometriosis does not help! TAH Will cease after menopause