Endometriosis & Adenomyosis
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
These conditions are probably underdiagnosed. Contrary to past perceptions, endometriosis is not uncommon in black patients & a common cause of 20 dysmenorrhea.
Diagnosis
- Pain is chronic, with exacerbations associated with menstruation
- Dysmenorrhea typically lasts through the period & may persist after
- Dyspareunia may be present
- Pain on defecation (dyschezia) may be due to endometriosis in the rectovaginal septum
- There may be infertility
- On examination - the uterosacral ligaments may be tender & nodular (posterior & lateral to the cervix on each side)
- Adenomyosis is a tender boggy uterus outside pregnancy
- Fixed uterine retroversion if endometriosis is severe
- Endometriomata may be palpable as an adnexal mass(es) or in the POD
- Chronic PID may produce similar signs – tenderness, fixation & an adnexal mass
Investigations
Laparoscopy with biopsy is the test for endometriosis. For adenomyosis it is sonar or MRI. The appearance of endometriosis at laparoscopy may vary from classical ‘powder-burns’, to vesicles, areas of fibrosis, or even normal appearing peritoneum; biopsy is definitive with two of the three – glands, stroma, haemosiderin. A therapeutic trial of progestogens has been recommended without laparoscopy in poorly resourced settings or when awaiting a scope – if effective it suggests the diagnosis. Adenomyosis is only confirmed at eventual hysterectomy.
Management
Nonsteroidal anti-inflammatories
Ibuprofen 400 mg po tds
Hormone preparations
Medroxyprogesterone acetate (Provera) 30 mg orally daily, or dydrogesterone (Duphaston) 5 mg orally twice daily, or gestrinone (Tridomose) 2.5 mg orally twice weekly, all for three months. Danazol is no longer frequently used because of unpleasant side-effects. Combined oral contraceptives given conventionally or without a withdrawal bleed. GnRH analogue drugs (e.g goserelin) are effective but expensive and cause menopausal symptoms and duration of use is limited by the side effect of osteoporosis(‘Add back’ means GnRH plus HRT).
Surgery
Options: ablation of endometriosis by diathermy or laser or argon beam coagulation, or surgical excision, adhesiolysis, & removal/ablation of endometriomas. Laparoscopic uterine nerve ablation (LUNA) is no longer in favour. TAH & BSO is only for extreme cases. Endometriomas operated on either laparoscopically or by laparotomy should not be pre-treated with GnRH analogues as planes of cleavage are lost; removal may not improve fertility; removal has a lower recurrence rate than ablation.