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Endometriosis, Adenomyosis, and Leiomyomas

Definition: presence of functioning endometrial glands and stroma outside the endometrial cavity

Incidence: 1-5 % of all women. Prevalence in infertile endometriosis, adenomyosis, leiomyoma, myxoma, fibroid, fiboid, fibrod women is as high as 20-40%, and in menopausal women 5 %

History: progression occurs in 60% of patients, but spontaneous regression can occur in up to 30% of patients

Histology: estrogen and progesterone receptors are present in endometriotic tissue, but at levels much lower than in normal endometriosis, adenomyosis, leiomyoma, myxoma, fibroid, fiboid, fibrod, endometreosis endometrium throughout the menstrual cycle

Etiology: endometriosis is a multifactorial disease

Retrograde menstruation

Coelomic metaplasia

Hematogenous or lymphatic spread

Altered immune recognition

Polygenetic inheritance (7% of first degree relatives)

Environmental toxins

Symptomatology: poor correlation between degree of pelvic pain and extent of endometriosis

Infertility Prolonged menses for eight or more days Dysmenorrhea Dyspareunia Pelvic pain

Diagnosis: the findings of a fixed, retroverted uterus, endometriosis, adenomyosis, leiomyoma, myxoma, fibroid, fiboid, fibrod, endometreosis adnexal masses, or cul-de-sac nodularity on pelvic exam may raise the suspicion of endometriosis, but are not diagnostic

Laparoscopy (BEST)

Ultrasound (US)

CA-125 (useful as a marker for recurrence only, very nonspecific)

Laparoscopic findings

Typical: powder burn lesions

Atypical

Red lesions (90% are endometriosis)

Clear lesions

White lesions (80% are endometriosis)

Peritoneal defects

Extrapelvic a. Appendix b. Diaphragm c. Colon/rectum

Classification

Revised American Society for Reproductive Medicine (ASRM classification (1985)

Advantages

Good reproducibility

Takes into account both the extent of the disease and endometriosis, adenomyosis, leiomyoma, myxoma, fibroids the amount of adhesions

Disadvantages

Deep endometriosis may be misclassified as minimal or mild disease

Extrapelvic endometriosis is not scored

Management of endometriosis in the presence of pelvic endometriosis, adenomyosis, leiomyoma, myxoma, fibroids pain ASRM classification (1993)

Pathophysiology

Pelvic pain

Direct nerve involvement (deep lesions)

Indirect nerve stimulation via cytokines

Infertility

Anatomic distortion

Activated macrophages

Cytokines

Immune system alterations

Treatment of pelvic pain

Surgery (first line of therapy)

Laparoscopy

Laparoscopy equal to laparotomy in effectiveness

Laser equal to electrosurgery in effectiveness

LUNA (laparoscopic uterosacral nerve ablation) only appropriate in cases of central dysmenorrhea (high recurrence within 6-9 months)

Presacral neurectomy as a last resort in cases endometriosis, adenomyosis, leiomyoma, myxoma, fibroids of severe central dysmenorrhea (high recurrence within 5 years)

Bowel prep in eases of advanced disease

Neomycin 500 nag, 2 fms @ 9 pm preop night endometriosis, adenomyosis, leiomyoma, myxoma, fibroid, fiboid, fibrod, endometreosis