gynecology lecture

1. Endometriosis and adenomyosis
Gaya 

2. “Presence of endometrial tissue other than the
lining of endometrial cavity “
Common in reproductive age 1-2 %
Most common benign gynaecological condition ,it is
oestrogen depend and its resolve after menopause.

3. Commonly occur in pelvic
• Ovaries
• Uterosacral ligament
• Pouch of Douglas
• Lateral pelvic wall
• Ovarian fossa

4. Extra pelvic
• Surgical scars
• Umbilicus
• Rectum
• Pleura
• Bladder

5. • Endometrial tissue respond to cyclical
hormonal changes and therefore undergoes
cyclical bleeding and local inflammatory
reaction .
• Repeat bleeding and healing cause fibrosis
• This cyclical damage cause adhesion between
associated organs causing pain and infertility

6. Ovaries endometriomas occurs due to
accumulation of blood as a result of repeated
sheading of the endometrial surface
This blood turns brown and resemble chocolate
colour therefore called as chocolate cyst

7. • Endometrioma: : Part of the condition known as endometriosis.
Endometrioma is a type of cyst formed when endometrial tissue
(the mucous membrane that makes up the inner layer of the
uterine wall) grows in the ovaries. It affects women during the
reproductive years and may cause chronic pelvic pain associated
with menstruation.
• Endometriosis is the presence of endometrial glands and tissue
outside the uterus.
• Women with endometriosis may have problems with fertility.
• Endometrioid cysts, often filled with dark, reddish-brown blood,
may range in size from 0.75-8 inches.

9. Surgical management of endometriomas
drained laparoscopically and the cyst wall can
be excised .
In situation where the cyst wall cannt be peeled
off it can be diathermised .
It is not recommended to use diathermy in
women who are planning to conceive bacause
of heat damage to ovaries

10. Etiology of endometriosis
• Etiology is unknown
• There are several theories
1) Implantation theory
Direct implantation of endometrial tissue can
grow in the newly implanted tissue such as in
scar endometriosis

11. 2) Retrograde menstruation (sampson’s theory)
Endometrial cells which fall with menstrual blood
into the pelvis can implant and grow in new sites.
That’s why this is common in ovaries POD lateral
pelvic wall
3)Coelomic metaplasia theory
Coelomic epithelium can undergo metaplastic
change in to endometrial tissue. This theory can
explain endometriosis in pleura and peritoneal
cavity.

12. 4) Vascular and lymphatic spread
Vascular and lymphatic embolization of
endometrial tissue can explain occurrence of
endometriotic deposits in usual site outside the
peritoneal cavity

13. American Fertility Association classified
endometriosis in to 4 stage –
mild/minimal/moderate/sever base upon
How deep the peritoneal and ovarian
endometriosis is
How badly the POD is obliterate due to adhesion
How dense the adhesions are on each tube and
ovary

14. Symptoms
• Sever cyclic non colicky pelvic pain (pain
typically starts with or after the onset of
menses and out lasts the period .
• Dysmenorrhea
• Deep dyspareunia- due to presents of
endometrial tissues in pouch of Douglas

15. Pelvic pain may be associated with irritable
bowel syndrome
If distinct site affected can cause local symptoms
Cyclic epistaxis with nasal passage deposit
cyclical rectal bleeding with bowel
deposits

17. Physical examination
• Bimanual vaginal examination very helpful to
diagnosis
• On speculum examination
• Purplish endometriotic nodules may be visible
in the posterior fornix
• Tender nodules felt along utero-sacral
ligament
• Tender fornices and pouch of Douglas and
adnexal mass or fixed retroverted uterus.

18. • Sometimes palpable mass can be felt in
adnexae if there are adhesion or
endomertiomas

19. Investigation
• CA 125 level is raised in endometriosis
• It can be diagnosis by the TV-USS –detect
gross endometriosis involving the ovaries
(endometrioma) .In smaller USS is of limited
value
• MRI detect >5mm in size particularly in deep
tissue (rectovaginal septum)

20. • Laparoscopy
Gold standard of diagnosis is laparoscopy.
Typical endometriotic deposits can be seen on
laparoscopy with adjacent scarring of the tissue.
Depend on experience of laparoscopist -base on
the accuracy of visual diagnosis of
endometriotic lesion .
Lesion can be red .puckered . Black ‘matchstick’
or white fibrous lesion

21. a)Red lesion in peritoneum
b)Black ‘matchstick’ lesions
a b

22. c)White fibrous lesion

23. Management
• Ei medical or surgical .No definitive cure is
available since the etiology of the disease is
not clearly understood yet
• Treatment should therefore be tailored for
the individual according to her age,
symptoms, extent of the disease and her
desire for future childbearing.

24. Medical management
Principle is to create a period of amenorrhoea
so that endometriosis tissue will undergo
atropic changes and endometriosis will undergo
regression
This can be achieved by either creating a
situation of pseudo-pregnancy or post
menopause

25. 1) Non-steroidal anti-inflammatory drugs (NSAIDs)
are potent analgesics and are helpful in reducing
the severity of dysmenorrhoea and pelvic pain.(
The additional use codeine/opiates should be avoided as the coexisting
irritable bowel symptoms can be worsened,exacerbating pelvic pain
symptoms )
2) Progesterone injection in high dose . Depo-
provera is usually given in a dose of 150 mg IM
every 4 weekly or continue oral tablet .use of
levonorgestrel IUD effective

26. 3) OCP can be given continuously without the
dummy tablets so there is no breakthrough
bleeding for minimal 6 month period If there is
symptomatic relief with the continuous use of
COC, then this therapy should be continued
indefinitely for up to several years or even
longer until pregnancy is intended.

27. 4) Danozol which has antiestrogenic properties is given to
create post menopausal changes leading to endometrial
atrophy
There are androgenic side effects like weight gain ,acne ,
hirsutism , can limit its use.
5) Gonadotrophin-releasing hormone agonists
(GnRH-A) are as effective as danazol in relieving
the severity and symptoms of endometriosis by giving
hypoestronic change

28. These can be administered as nasal spray or IM
depot preparation .long term therapy cause
menopausal effects like osteoporosis hot flush
and night sweating like.
The administrate low dose oestrogen therapy
(HRT) –addback is given to prevent this

29. Surgical management
• Conservative surgery
Laparoscopic surgery with techniques such as
diathermy , laser vaporization , or excision has
become the standard for surgical management.
In mild to minimal endometriosis purple –brown
spots can be seen in pelvis with scarring and
puckering of the adjacent tissue . These are
called ‘café-au-lait spots.

30. • When surgery is done foe women with
subfertility adhesiolysis is performed to make
the tube and ovaries mobile .it is also
important to clear the POD of adhesion
• Patient who complaining subfertility .fertility
treatment should proceed immediately
following surgical clearance

31. • Aim of treatment is to make the patient pregnant
before the adhesion formation and impair the
tubal motility .so medical treatment for endo.
Not recommend after surgery .
• Since pregnancy is the nature sure for
endometriosis any women with evidence of
endometriosis should be encouraged to get
married and pregnat early

32. • Definitive treatment
Sever symptoms and progressive disease or in
women whose families are complete
hysterectomy and B/L salphingo –oophorectomy
which is usually curative .
HRT 6 month following surgery

36. Adenomyosis
• It is disorder which is endometrial gland found
deep within the myometrium ,
• Etiology yet unknown
• Patients are usually multiparous and diagnosis
in their late 30s or early 40s
• Patients are present with increasing sever
secondary dysmenorrhea and increasing
menstrual blood loss

37. • On examination find bulky and sometimes tender
‘boggy’ uterus .
• USS examination of uterus may be helpful in
diagnosis –shows haemorrhage filled ,distended
endometrial glands ,some times irregular nodules
development can be seen. (similar to fibroid )
• MRI is the more definitive investigation of choice
as it provides excellent image of myometrium and
endometrium and areas of adenomyosis

38. • MRI images of adenomyosis.

39. • Conservative medical and surgical treatment
poorly response
• Any treatment which induce amenorrhea will
be helpful. –relive pain and excessive bleeding
• symptoms rapidly return in the majority of
patients, and hysterectomy remains the only
definitive treatment.