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Slide 1
Endometriosis & Adenomyosis Omar Al Omari, MRCOG
Obstetrician & Gynaecologist Jordan Hospital Medical Center
1
Slide 2
2 Endometriosis
Slide 3
3 Definition : Abnormal growth of endometrial tissue outside
the uterine cavity.
Slide 4
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
Slide 5
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
Slide 6
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.
Slide 7
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
Slide 8
8 The pathogenesis is unclear. multifactorial
Slide 9
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
Slide 10
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.
Slide 11
11
Slide 12
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
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.
Slide 15
15 Upon closer view, these five small areas of endometriosis
have a reddish-brown to bluish appearance.
Slide 16
16 Pathology microscopic appearance Histomorphologically
similar to eutopic endometrium Four major components endometrial
glands endometrial stroma fibrosis hemorrhage
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.
Slide 20
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
Slide 21
21 Diagnosis History PV examination Laparoscopy golden standard
Ultrasonography Btype ultrasound CA125 200U/ml normal value 35U/ml
Antiendometrium antibody +
Slide 22
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
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.
Slide 26
26 Medical therapy Indications chronic pelvic pain severe
dysmenorrhea no require to get pregnant no ovarian cyst formation
Hormoneinhibition therapy
Slide 27
27 Drugs Danazol pseudomenopause therapy Gestrinone GnRH a
medical oophorectomy add back therapy Mifepristone RU486
Progestogens pseudopregnancy therapy
Slide 28
28 Surgical therapy 1 Indications 1 adnexal mass 2 pelvic pain
3 infertility Approaches (1) trans abdominal (2) laparoscopic
Slide 29
29 Surgical therapy 2 Methods Conservative surgery 1)preserve
the fecundity 2)preserve the ovarian function Definitive surgery
hysterectomy + salpingooophorectomy
Slide 30
30 Combination medicalsurgical treatment Threestep surgery
medical therapy second look laparoscopy
Slide 31
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
Slide 32
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.
Slide 33
33 Prevention Avoid possible augmentation of menstrual reflux.
Taking oral contraceptive is recommended. Isolation and irrigation
of the operative site.
Slide 34
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.
Slide 35
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.
Slide 36
36 Adenomyosis
Slide 37
37 Definition A benign uterine condition in which endometrial
glands and stroma are found deep in the myometrium.
Slide 38
38 Etiology Basal endometrial hyperplasia invading a
hyperplastic myometrial stroma. Four primary theories Heredity
Trauma Hyperestrogenemia Viral transmission
Slide 39
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.
Slide 40
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.
Slide 41
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
Slide 42
42 Clinical features 2 Most common physical sign a diffusely
enlarged uterus (rarely exceeds 12 weeks gestation in size)
particularly tender during menstruation
Slide 43
43 Diagnosis History Pelvic examinations Ultrasonography Serum
markers CA-125
Slide 44
44 Treatment Hormone therapy Hysterectomy the only uniformly
successful treatment for adenomyosis is necessary.