Endometriosis and Adenomyosis - NEET PG

Endometriosis and adenomyosis are important topics for the NEET PG exam. These are gynecological conditions that can cause significant symptoms and complications for affected women. As such, they are covered in the syllabus of NEET PG, and a strong understanding of these conditions is important from the exam point of view.

In this medical notes blog, we have covered all important details pertaining to the topic. Read it further for a quick overview.

Endometriosis

Endometriosis is a medical condition in which the tissue that normally grows inside the uterus grows outside of it, resulting in pain and potential infertility. It can affect various parts of the body including the ovaries, fallopian tubes, and pelvic cavity.

Etiology: Retrograde Menstruation

• Proposed by Sampsons [Sampsons Implantation Theory]: endometrium also goes out through tubes (retrograde) and implants on ovary, ligaments, bowel
• 70 to 80 % of all women have retrograde menses
• 5-10% of all women have poor immunity & ↑estrogenecity & develop endometriosis

Related Previous Year's Questions

Q. 18 year old girl presents with partial transverse vaginal septum with dysmenorrhea and chronic pelvic pain. Which of the following is the likely complication? 

A. Endometriosis

B. Tubo-ovarian abscess

C. Dermoid cyst

D. Theca Lutein cyst

Age of Presentation: 3rd to 4th decade [25-35 yrs of age]

Diagnosis

• ↑CA 125
• USG, MRI
• Laparoscopy [best]

Sites of Predilection

Some common sites of endometrial tissue growth include:

• MC site: ovary
• 2^nd mc site: POD
• Bowel
• Vicarious Menstruation
  • Lung [periodic hemoptysis]
  • Nose [Periodic epistaxis] Vicarious Menstruation 
  • Eyes [Periodic sub conjunctival hemorrhage]

Pathology

• Powder Burn Lesions/Blue Spots
• Chocolate Cyst of Ovary: endometrium sheds in ovary and since it cannot come out, keeps collecting to form a cyst
• Scarring & adhesions with fallopian tube: in the process of healing - causes Infertility by impairing oocyte pick up by fimbria

Symptoms

Endometriosis can cause a range of symptoms, including - 

• Chronic pain
• Acute monthly exacerbation: Severe congestive dysmenorrhea
• Deep dyspareunia
• Menorrhagia
• Infertility
  • Altered tubo-ovarian relation by adhesion, impairing oocyte pick up
  • Intercourse
  • Poor ovulation
  • Embryotoxic Endometriotic Deposits
    • Poor quality embryos
    • ↓implantation
    • ↑Abortion

Previous Year's Questions

Q. A woman with endometriosis is likely to suffer from it?

A. Infertility and dysmenorrhea

B. Infertility and irregular vaginal bleeding

C. Dysmenorrhea and Irregular vaginal bleeding

D. dysmenorrhea and Vaginal discharge

Q. A nulliparous 29-year-old woman presents with infertility. On examination, uterus is felt to be normal in size but is retroverted and fixed. Also. there is tenderness in posterior vaginal fornix. Diagnosis?

A. Adenomyosis

B. Endometriosis

C. Fibroid uterus

D. Ovarian malignancy

Treatment

Treatment options for endometriosis include: 

Surgical Rx

• Adhesiolysis for adhesion
• Cystectomy for chocolate cysts
• Ablation for deposits: Fulgration of Deposits
  • Thermal or Laser
• 60-70% Recurrence
• Other options:hysterectomy

Medical Management

1. INJ Depo medroxyprogesterone acetate 150 mg once in 3 months
   • Creates pseudopregnancy state : progesterone stabilizes endometrium
   • Atrophy of endometrium in 3-4 months of Rx
2. Tab Danazol
   • Androgen: Antiestrogenic action
   • Faster atrophy
   • Side Effect: Hirsutism: reversible change Virilization
     • Breast atrophy 
     • Hoarseness of voice Irreversible 
     • Clitromegaly Irreversible
   • 1^st sign to stop Rx with Danazol: Hoarseness of voice
3. Combined oral contraceptive pills
   • Anovulatory cycles: Painless
   • Limits endometriosis
4. GnRH Analogues: Depot or Continuous Form
   • Leuprorelin, Naferelin, Goserlin
   • Normal GnRH secretion is pulsatile. Here, G n R H is given as depot/continuous form causing excessive stimulation of pituitary, ultimately causing desensitization/ down regulation of pituitary receptors

Understand with an example

Ques. 25 yrs with chocolate cyst. Surgery is done: what next?

Ans. Medical management till conception

• Pregnancy: limits endometriosis family complete start on COCPs
• COCPs: 21 × 4 packs

• 84 days continuously
• Periods once in 90 days

• GnRH analogues
  • 6 months

→ Estrogen dependent osteoblastic action will stop 

→ Estrogen independent osteoblastic action will continues Osteoporosis

• Add Back Regime; to be started if GnRH are to be given for longer than 6 months: Low dose estrogens and RALOXIFENE [selective estrogen receptor modulator]

Previous Year's Questions

Q. 29 year old nulliparous lady presented with endometriosis and infertility. On laparoscopy there were severe pelvic adhesions and uterus had bowel stuck to its fundus with dense adhesions. The ovaries were cystic each around 6 - 8 cm in size and stuck to each other (kissing ovaries). What is the next line of management?

A. GnRH analogues

B. OCPs

C. Hysterectomy with oophorectomy

D. B/L cystectomy with adhesiolysis and plan for IVF

Adenomyosis/endometriosis Interna

Adenomyosis is a condition in which the endometrial tissue, which normally lines the uterus, grows into the muscular wall of the uterus. 

Seen in

• Multiparous women
• >40 yrs
• 30% of hysterectomy specimens

Endometriosis Interna

• Endometriosis within the uterus, in the muscle layer. Due to disruption of endometrial-myometrial border due to repeated pregnancies

Associated with

• Menorrhagia
• Progressive dysmenorrhea
• Infertility in young women [Rare]
• Uterus: Uniformly enlarged <14 weeks size of pregnant uterus [14cm] (asymmetrically enlarged uterus in fibroid)

Previous Year's Questions

Q. A 38 year old P3L3 woman presents with secondary dysmenorrhea and on USG there is uniform enlargement of uterus upto 10 cms. What is the provisional diagnosis? (FMGE 2020)

A. Adenomyosis

B. Fibroid

C. Leiomyoma

D. Endometriosis

Diagnosis

Diagnosis of adenomyosis is typically made through a combination of a medical history review, a physical examination, and imaging tests such as an ultrasound, MRI, or a hysterosalpingography. In some cases, a biopsy may be necessary to confirm the diagnosis.

1. USG,MRI

• Sub endometrial halo present
• Hetero echoic deposits in uterine myometrium
• III defined hypoechoic areas: Lakes of Endometrial Blood 
  • Junctional zone b/w endometrium & myometrium
  • Normal: 5-8 mm
  • Adenomyosis: >12 mm [diagnostic]

2. Uterine Biopsy/ Post Hysterectomy Uterine Analysis

• Endometrial glands within uterine muscles: Pathognomic
• Localized adenomyosis: fibroids have pseudocapsule. adenomyosis has diffuse border

Treatment

Treatment options for adenomyosis include:

• Menorrhagia: NSAIDS, Hormones
• Young women: Hormones
  • COCPs for longer duration
  • IUD with progesterone [mirena] localized excision
• Surgical Mx of Menorrhagia: D & C
• Overall best Rx: Hysterectomy

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