Benign disease of the uterus and cervix doc

Chapter 9
Benign disease of the uterus
and cervix
Epithelium
1
the uterine cervix
Endometrium
103
104
Myometrium: uterine fibroids
105
OVERVIEW
Benign disease o1 the cervix and body of the uterus is extremely common. Cervical ectropion and fibroids are often present with-
out symptoms, but are also common problems encountered in almost every gynaecological outpatient clinic. Adenomyosis and.
1
Endometriosis, other important benign conditions, are considered in Chapter 10.
Benign disea.se of the uterus may conveniently be
classified in terms of the tissue of origin: the uterine
cervix, the endometrium or the myonietrium.
Epithelium: the uterine cervix
The transformation zone it. a special feature of the ecto-
iervix, and corresponds to that portion of die uterine
cervix visible during speculum examination. Within this
aone the stratified squamous epithelium of the vagina
meets the columnar epithelium of the cervical canal.
The anatomical site of the squamocolumnar junction
fluctuates under hormonal influence, and the high cell
mrnover of this tissue is important in the pathogenesis
rf cervical carcinoma, discussed in Chapter 12. The
lotumnar epithelium is normally visible with the
ipeculum during the ovulatory phase of the menstrual

c»de. during pregnancy and in women taking the corn-
wed oral contraceptive pill, in whom oestrogen levels
arc elevated. In contrast, only squamous epithelium is
visible in a postmenopausal woman not taking hor-
mone replacement therapy.
Cervical ectropion
The presence of a large area of columnar epithelium on
the ectocervix can be associated with excessive mucus
secretion, leading to a complaint of vaginal discharge.
The appearance of the cervix is termed cervical ectro-
pion or, very inappropriately, a 'cervical erosion'. The
latter term is best avoided, as it conveys quite the
wrong impression of what is really a normal phenom-
enon. Ectropion can be associated with excessive but
non-purulent vaginal discharge, as the surface area
of columnar epithelium containing mucus-secreting
glands is increased. If the discharge associated wfth
cervical ectropion becomes troublesome to the patient,
discontinuing
the
oral contraceptive pill
or,
ahenn-
tively, ablative treatment under local anaesthesia using
a thermal probe can reduce it. This treatment involves
a metal probe that heats the tissue to around 100 "C,
104 Benign disease of the uterus and cervix
destroying the epithelium to a depth of 3—1 mm. The
technique is sometimes confusingly termed 'cold coagu-
lation'to distinguish it from more destructive diathermy

or laser treatment of the cervix. A less glandular epithe-
lium regenerates after the procedure.
Cervical ectropion may also give rise to postcoital
bleeding, as fine blood vessels present within the
columnar epithelium are easily traumatized. This
symptom may be very distressing as well as embarrass-
ing, but a direct question should always be asked when
taking the gynaecological history because of its associ-
ation with cervical carcinoma. Reassurance about the
cause and treatment as described above can be given
after obtaining a normal cervical cytology result.
Nabothian follicles
Within the transformation zone of the ectocervix the
exposed columnar epithelium undergoes squamous
metaplasia. Glands contained within columnar epithe-
lium may become roofed over with squamous cells,
resulting in the formation of small (2-3 mm) mucus-
filled cysts visible on the ectocervix. These are termed
Nabothian follicles, and are of no pathological signifi-
cance, larger (up to 10mm) Nabothian follicles are
occasionally identified coincidentally during transvagi-
nal ultrasound scanning, but do not require treatment.
Endometrium
The uterine endometriurn comprises glands and
stroma with a complex architecture, including blood
vessels and nerves. As discussed in detail in Chapter 4,
during the follicular phase of the menstrual cycle,
proliferation of tissue from the basal layer occurs, fol-
lowed by secretory changes under the influence of
progesterone after ovulation and finally shedding as

progesterone levels tall, with corpus luteum regression.
Disturbances of prostaglandin biosynthesis within the
endometrium may give rise to menstrual disorders
(see Chapter 5), but the increased use of endoscopy
and ultrasound has given more specific appreciation of
visible abnormalities of the endometrium.
Endometrial polyps
Historically, a diagnosis of'dysfunctional uterine bleed-
ing was made in women with menstrual disturbance in
whom curettage provided a histologically normal sam-
ple of endometrium. In current practice, hysteroscopy
or ultrasound enables the identification of endomet-
rial polyps that may be the cause of abnormal bleeding,
especially intermenstrual bleeding. These polyps typi-
cally occur in women aged over 40 years. Intermen-
strual bleeding in younger women is more likely to be
a consequence of combined or progestogcn-only
contraceptive pill use or the wearing of an intrauterine
contraceptive device (IUCD), and is less likely to
require investigation. In perimenopausal or post-
menopausal women with abnormal bleeding, the first
priority is to exclude endometrial malignancy, but in
many patients the cause will turn out to be a benign
polyp that can be removed at hysteroscopy. Reflecting
typical clinical experience, polyps were detected by
outpatient hysteroscopy in 11 per cent of 2581 women
referred for the investigation of menstrual symptoms.
After the menopause the endometrium is normally
atrophic, but hormone replacement therapy does pro-
vide endometrial stimulation, leading to polyp forma-

tion. Women presenting special diagnostic problems
are those taking tamoxifen for the treatment of breast
cancer. This agent is a partial oestrogen agonist with
inhibitory effects on breast tissue. However, the
endometrium is stimulated, sometimes leading to
polyp formation or even endometrial hypcrplasia
and malignancy. Ultrasound assessment is difficult
because the drug affects the sonographic properties of
the inner myometrium, giving the misleading impres-
sion of a greatly thickened endometrium.
Asherman's syndrome
When [he endometrium has been damaged, in particu-
lar when it has been removed down to or beyond the
basal layer, normal regeneration does not occur, and
instead there is fibrosis and adhesion formation, termed
Asherman's syndrome. This phenomenon is exploited
therapeutically in endometrial resection, a surgical
treatment for menorrhagia in which the endometrium
is resected using a diathermy loop or is ablated with a
laser, in each case beyond the basal layer into trw
myometrium so that regeneration cannot occur. The
result is reduced, or absent, menstrual shedding.
Asherman's syndrome occurs as an adverse con-
sequence of excessive curettage, especially at the time
of evacuation of retained placental tissue after mis-
carriage or secondary postpartum haemorrhage. In a
hysteroscopic follow-
ation following reiaii
adhesions within the
cent, and these were

strual symptoms. Tre
;> ndromc include mai
ine walls by insertion
a Lippes loop (now ol
pose) or hysteroscopic
Other causes of AsJ
particular parts of it
schistosomiasis.
Complications of ci
When premalignant d
by knife cone biopsy,
ferred technique of i
Chapter 12), subseque
mon. This is now less c
rise to haemalometra a
in the endometrial cai
fcbtory are arnenorrho.
eal dysmenorrhoea-liki
of cervical surgery. In p
eal stenosis may give
accumulated secretions
Underlying malignanc
Treatment is by careful'.
•id endometrial bio]
bally,
a
cervix
not co
iom previous surgery t
.xrvical dystociai, nece

°edunculated
fibroid
lntracavity__
polyp "
H
Intramural
Myometrium: uterine fibroids 105
been damaged, in partial- I
d down to or beyond the
tjon does not occur, and
Ihesion formation, termed
phenomenon is exploited
iial resection, a surgicJI
n which the endometriurr.
v loop or is ablated with a
the basal layer into the
cration cannot occur. The
nenstrual shedding.
ccurs as an adverse con-
tage, especially at the time
placental tissue after mis-
partum haemorrhage. In *
hysteroscopic follow-up study after surgical evacu-
ation following retained placenta, the prevalence of
adhesions within the endometrial cavity was 20 per
cent, and these were strongly associated with men-
strual symptoms. Treatment options tor Asherman's
syndrome include maintaining separation of the uter-
ine walls by insertion of a large inert IUCD such as
a Lippes loop (now obsolete other than for this pur-

pose) or hysteroscopic lysis of intrauterine adhesions.
Other caLises of Asherman's syndrome relevant in
particular parts of the world are tuberculosis and
schistosomiasis.
Complications of cervical stenosis
When premalignant disease of the cervix was treated
by knife cone biopsy, rather than the currently pre-
ferred technique of diathermy loop excision (see
Chapter 12), subsequent cervical stenosis was com-
mon. This is now less commonly seen, but it may give
rise to haematometra as menstrual blood accumulates
in the endometrial cavity. Suggestive features in the
history are amenorrhoca associated with severe cycli-
cal dysrnenorrhoca-like pain, with a previous history
of cervical surgery. In postmenopausal women, cervi-
cal stenosis may give rise to pyometra, in which
accumulated secretions become a focus of infection.
Underlying malignancy may also lead to pyometra.
Treatment is by careful surgical dilatation of the cervix
and endometrial biopsy under antibiotic cover.
Finally, a cervix not completely stenosed but scarred
from previous surgery may fail to dilate during labour
cervical dystocia), necessitating Caesarean section.
Myometrium: uterine fibroids
Pathology
A fibroid is a benign tumour of uterine smooth mus-
cle, termed a leiomyoma. The gross appearance is of a
firm, whorled tumour located adjacent to and
bulging into the endometrial cavity (submucous
fibroid), centrally within the myometrium (intra-

mural fibroid), at the outer border of the
myometrium (subserosal fibroid) or attached to the
uterus by a narrow pedicle containing blood vessels
(pedunciliated fibroid) (Fig. 9.1). Fibroids can arise
separately from the uterus, especially in the broad lig-
ament, presumably from embryonal remnants. The
typical whorled appearance may be altered following
degeneration, three forms of which are recognized:
red, hyaline and cystic.
Red degeneration follows an acute disruption of the
blood supply to the fibroid during active growth, classi-
cally during pregnancy. This may present with the sud-
den onset of pain and tenderness localized to an area ot
the uterus, associated with a mild pyrexia and leukocy-
tosis. The symptoms and signs typically resolve over a
few days and surgical intervention is rarely required.
Hyaline degeneration occurs when the fibroid
more gradually outgrows its blood supply, and may
progress to centra! necrosis, leaving cystic spaces at
the centre, termed cystic degeneration. As the final
stage in the natural history, calcification of a fibroid
may be detected incidentally on an abdominal X-ray
in a postmenopausal woman. Rarely, malignant or
sarcoma to us degeneration has been said to occur, hut
Pedunculated
fibroid
Intracavity
polyp
Intramural
Figure 9.1 Typical location of uterine fibroids.

._ Subserous
sii#-
- - -
Submucosal
- Cervical
106 Benign disease of the uterus and cervix
P Understanding the paihophysiology
Aetiology
A range of hypotheses accounting lor the pathogenesis
o1 fibroids has been explored. The key features of jterine
leiomyomata are their occurrence during the reproductive
years, where ovarian hormone levels are high, their diverse
manifestation as either single or multiple tumours, and
the existence of racial and familial predisposition. Trie
possibility of abnormal oesirogen receptor expression has
been explored and discounted: both main progesterone
receptor subtypes are expressed similarly in myoma and
normal myometriijm. Thus myoma lissje is still influenced
by ovarian hormones. Experimentally, progesterone has
been shown to stimulate the production of both an
apoptosis-inhibiting protein and epidermal growth factor
(EGF) in cultured myoma tissue Oestradiol has the effect
of stimulating expression of the EGF receptor
Reduced expression of growth inhibitory factors such as
monocyte chemotactic protein-1 (MCP-1) may play a part in
the loss of inhibition required for fibroid growth. Treatment
by ovarian suppression (see below) is associated with an
increase in matrix metalloproleinase (WIMP) expression and
a decrease in metalioproteinase inhibitory (TIMP) activity,
which suggests that ovarian hormones have a role in

maintaining the architecture of a myoma once formed.
Cytogenetic studies have identified specific features of
uterine myoma tissue compared to normal myornetriurn
and to leiomyosarcoma. It appears that cells within srt
malignancy probably arises through a separate path-
way of chromosomal deletions (see the box above)
and the real possibility of malignant change in a
fibroid is vanishingly small.
Clinical features
Fibroids arc common, being detectable clinically in
about 20 per cent of women over 30 years of age.
Autopsy studies with systematic histology of the uterus
show a prevalence of up to 50 per cent. Risk factors for
dmkaily significant fibroids are nulliparity, obesity, a
•stive family history and African racial origin. The
" r:t\ do nol cause symptoms but may he
- " " " :: . incidentally, for example at the time ul'
, a cenical smear or performing laparoscopic
Common presenting complaints are
individual myoma are monoclonal in origin, but cells
from different myomas within the same uterus are of
independent origin. It is likely that the clonal expansion of
tumour cells precedes the development of cyto-genetic
aberrations, but the latter may determine the clinical course,
depending on the extent to which control over growth is
lost Some evidence for this is provided by cytogenetic
analysis, which showed a greater proportion of karyotypic
abnormality in larger, compared to smaller, fibroids. The
most common cytogenetic aberrations detected have been
on chromosomes 12, 6, 3 and 7, a ring chromosome!, and

translocation involving chromosomes 12 and 14. Relevant
areas of chromosomes 12,6 and 7 are thought to contain
putative growth-regulating or tumour-suppressor genes. It
is not yet clear to what extent the cytogenetic features can
be correlated with the clinical picture.
Tne possibility of malignant transformation of a fibroid
to a leiomyosarcoma has traditionally been cited as a
reason to recommend surgery for fibroids, with a stated
risk of up to 05 per cent. However, current opinion is that
where a sarcoma develops in the presence of fibroids, the
association is coincidental and malignant transformation
of a fibroid is unlikely. The cytogenetic evidence gives
some basis for reassurance on this point, as the typical
findings in leiomyosarcoma tissue are of more extensive
genetic instability with frequent deletions, especially
involving chromosomes 1 and 10.
menstrual disturbance and pressure .symptoms, espe-
cially urinary frequency. Pain is unusual except in the
special circumstance of acute degeneration discussed
above. Menorrhagia may occur coincidentally in a
woman with fibroids; it is likely that only submucous
fibroids distorting the endomeirial cavity and increas-
ing the surface area are truly causal.
Snbfertility may result from mechanical distortion or
occlusion of the h'allopian tubes, and an endometrial
cavity grossly distorted by subrrmcous fibroids may
prevent implantation of a ferlili/ixi ovum. Once a preg-
nancy is established, however, the risk of miscarriage is
not increased. In late pregnancy, fibroids located in the
cervix or lower uterine segment maybe the cause of an

abnormal lie. After delivery, postpartum haemorrhage
may occur due to inefficient uterine contraction.
Abdominal examination might indicate the pres-
ence of a firm mass arising from the pelvis, and on
bimanual examinatio
the uterus, usually wil
Differential diagnc
Other causes of an al>
in the reproductive yt
uterus enlarged with I
trast to a uterus enlar
ian tumour, whether b
secondary, may enlar;
clinically difficult to
fibroid, Leiomyosara
history of a rapidly ei
There may be less
expected with a fibroii
Investigations
Often the clinical feat
establish the diagnosis
will help to indicate ai
nificant menorrhagia.
distinguish a uterine f
of the renal tract may
large fibroid to exclud
sure from the mass on
of sarcoma will be an i
more likely, urgent lap,
Treatment

Conservative manage
asymptomatic fibroids ,
be useful to establish th
repeat clinical examinai
month interval. Where
practical currently avail
ian suppression using a
mone (GiiRH) agont
effective in shrinking fi
returns, the fibroids rq
sions. Mifepristone (a
shown to be effective in :
bui is not available for i
mal dose, duration of ti
have yet to be establish*
Myometrium: uterine fibroids 107
binianual examination the mass is felt to be part of
the uterus, usually with some mobility.
• origin, butcefc
rrw utems are of
donal expansion of
erf ol cytogenetic
Bine Hie clinical course,
Iro! over growth is
dad by cytogenetic
qportton of karyotypic
Blatter fibroids. Trie
as detected nave been
ring chromosome t, and
es 12 and 14. Relevant

are thought to contain
ur-sup press or genes. It
jtogenetic features can
ft
reformation of a fibroid
ally
been
cited
as a
•Rjroids, with a slated
r, current opinion is thai
presence ol fibroids, tne
iBgnant transformation
netic evidence gives
is point, as the typical
e are of more extensive '
Bletions, especially
essure symptoms, espe-
is unusual except in the
degeneration discussed
cur coincidental] y in a
Jy that only submucous
etria) cavity and increas-
ausal.
mechanical distortion or
bes, and an endomttrial
ubmucous fibroids may
feed ovum. Once a preg-
the risk of miscarriage is
cy, fibroids located in the

at may be the cause of an
wstpartum haemorrhage
rterinc contraction,
night indicate ihe pres-
from the pelvis, and on
Differential diagnosis
-
Other causes of an abdominopelvic mass in a woman
in the reproductive years need to be considered. The
uterus enlarged with fibroids is typically firm in con-
trast to a uterus enlarged with a pregnancy. An ovar-
ian tumour, whether benign or malignant, primary or
secondary, may enlarge to occupy the pelvis and be
clinically difficult to differentiate from a uterine
fibroid. Leiomyosarcomas typically present with a
history of a rapidly enlarging abdominopelvic mass.
There may be less mobility of the uterus than
expected with a fibroid and general signs of cachexia.
Investigations
Often the clinical features alone will be sufficient to
establish the diagnosis. A haemoglobin concentration
will help to indicate anaemia if there is clinically sig-
nificant menorrhagia. Ultrasonography is useful to
distinguish a uterine from an ovarian mass. Imaging
of the renal tract may be helpful in the presence of a
large fibroid to exclude hydronephrosis due to pres-
sure from the mass on (he ureters. Clinical suspicion
of sarcoma will be an indication for needle biopsy or,
more likely, urgent laparotomy.
Treatment

Conservative management is appropriate where
asymptomatic fibroids are detected incidentally. It may
be useful LO establish the growth rate of the fibroids by
repeat clinical examination or ultrasound after a 6-12-
month interval. Where treatment is required, the only
t practical currently available medical treatment is ovar-
nn suppression using a gonadof rophin-releasing hor-
mone (GnRH) agonist. Unfortunately, while very
effective in shrinking fibroids, when ovarian function
returns, the fibroids regrow to their previous dimen-
sions. Mifepristone (an aniiprogestogen) has been
shown to be effective in shrinking fibroids at a low dose,
but is not available for use in this indication. The opti-
mal dose, duration of treatment and long-term effects
Tave yet to be established.
Figure 9.2 Hysteroscopic appearance of a fibroid polyp
within the endometrial cavity. (Kindly supplied by
Mr ED Alexopoulos.)
The choice of surgical treatment is determined by
the presenting complaint and the patient's aspirations
for menstrual function and fertility. Menorrhagia asso-
ciated with a submucous fibroid or fibroid polyp (Fig.
9.2) may be treated by hysteroscopic resection. Where a
bulky fibroid uterus causes pressure symptoms, the
options are myomectomy with uterine conservation,
or hystereclomy. Myomectomy will be the preferred
option where preservation of fertility is required, but
care must be taken in the management of a subsequent
pregnancy, as the uterus may be predisposed to rup-
ture. It is traditionally held that uterine rupture during

pregnancy is more likely wben the endometrial cavity
has been entered during myomectomy, but, not sur-
prisingly, there are few data to confirm or refute this. In
any event, the decision to undertake myomectomy in a
woman who desires future fertility needs to be care-
fully considered and the benefits and risks fully dis-
cussed with the patient. An important point for ihe
preoperative discussion is that there is a small but sig-
nificant risk of uncontrolled bleeding during myomec-
lotny, which could lead to the need for hysterectomy.
Hysterectomy and myomectomy can be facilitated
by GnRH agonisi pretreatment over a 2-month period
to reduce the bulk and vascularity of the fibroids.
Useful benefits of this approach are to enable a
Pfannensteil (low transverse) rather than a midline
abdominal incision, or to facilitate vaginal rather than
abdominal hysterectomy, both of which are conducive
to more rapid recovery and fewer postoperative com-
plications. A technical problem with myomectomy
after GnRH agonist pre-treatment is that die tissue
planes around the fibroid are less easily defined, but
on the positive side, blood loss and the likely need for
transfusion are reduced.
108 Benign disease of the uterus and cervix
Figure 9.3 Magnetic resonance imaging appearances of uterine fibroids (a) before and (b) after uterine artery embolization. (Kindly
supplied by Dr N Hacking.)
Management
Pelvic exam in a tin n often reveals an enlarged and ten-
der uterus. If the woman has no symptoms and the
uterus is not enlarged, no Treatment is indicated. If

the woman is symptomatic, hysterectomy is usually
the preferred treatment, since adenomyosis does not
respond well to hormonal treatment.
New developments
Endoscopic surgical treatments for fibroids have proved
disappointing: myolysis using a diathermy needle to destroy
the tissue is followed Oy intense adhesion formation. Given
the requirement for a substantial blood supply to support
growth, interruption of the arterial supply to the tumour is a
theoretically attractive concept. In practice, this is feasible
by the radiological technique of percutaneous selective
cathetenzation o1 the uterine arteries. Microparticles are
released into the vessels, causing occlusion of both uterine
arteries Sufficient collateral circulation is present from the
ovarian arteries to sustain normal uterine metabolic require-
ments, and women experience a substantial reduction in
fibroid bulk, together with improvement in menstrual symp-
toms over the following 6 months. Currently available fol-
low-up data suggest that the symptomatic improvement is
sustained. Figures 9.3a and b show contrast-en ha iced
magnetic resonance imaging (MRI) of a fibroid uterus
before and after embolization of the uterine arteries.
CASE HI!
Mrs AR a 37-year-old
cleaner in a local hosp
increasingly heavy, ret
complains of increase:
standing. There is no i
history is normal. She
retain her fertility as sr

a non-smoker and otto
the abdomen is distent
consistent with that of
exam in all on confirms \
two large fibroids that;
subs era us.
Additional reading
*xopoulosED,
Fay TN, Sir
diagnostic hysteroscopies
uterine bleeding. Gynaeco
.ethaby A, Vollenhoven 6.1
QonarJotropin-releasing hoi
• Cervical ectropion is a very common finding and may be
associated with chlamydial infection
• The aetiology of fibroids is unknown, but growth is
oestrogen dependent.
• fibfoids are common, being detectable clinically in about
20 per cent of women over 30 years of age.
• Risk factors for fibroids are nulliparity, obesity, a positive
bniy
history
and
African
racial
origin.
• -•
_-•-•
:::
-i^rornsgia

may
include
a
•edwcaJ
obstruction
to
venous drainage
and
also increased total surface area of the endometrium
and disorders of prostaglandin synthesis and
metabolism.
The mechanism whereby fibroids affect fertility
is unclear.
Hysteroscopic techniques for the removal ot submucous
fibroids are becoming popular to avoid major surgery.
Hormone replacement therapy is not contraindicated in
postmenopausal women with fibroids
ittery pmbolization (Kindly
Mr^AP, a 37-year-old Afncanivoman who works asa
ejeaner
in a
loci!
hospital, presents with
3
history
of
inc'easlngly nea^y regular, pain I ul periods S he also-
compla-nacf mcrea&ed unnaryfraguflncy especially on
standing There is no irregular bleed-ing andlhe smear
history

1
is
normal
She
lastwo
children
but
sllll
wishes
to
retain hei fertility a? she is planning 3 Ibi id. Siieis ma Tied,
d non-smoker and nthEThVisefitand 'null Qn examination,
the abdomen is uis'erided and Ifierei* a pe'i/ii: mass
consistent wilh that el a 20-week size pregnancy Vaginal
fl^miFialion conlirms tin sand ultrasound y
nvo large fibroids that dm inlramyometrul hut also
N1y»iriEtliiuiri ulertJie littmids In I
Discussion
Hov/ would you manage this patient?
Tbe lir.ponant farjior here is that Mrs AP i^ fibroids l
ennuih
t,n
HUSP
DDmpre&&ion
symptoms
and
mennirhagia
[' fibroids do not cause symptons, they can be ob&ervad.
Tbe olberimDOitrintlflalLiie i&that &hs wiphosto- retain hor
lertilily

andthsietorehysfflrecttimy
may b«
contralndicatfld
Mydaiectoiuy can be attempled and obviously theie is a
risk of Jleedlna and the patient must be warned tfiat she ^
may loafi tbp <ituni& ilthii^ is performed by lapjiotomy
Arridre modern option is emboliiatioiHl e obstructing
The uterine artery by an Injection of a vanetyof su&stances
to Hu&e necrosis of tbe fibroid}
reading
Alenopoulos ED, FayTN SimnnisfiD fl nivin
1
.
1
.
1
of 35fl1 out-patiant
diagrosi c h^steroscoples in Ibe management of abnormal
utpnnc bleeding. Gj™scQV£mtasoflpy1989; 8:105-10.
_ethal)yA, Vollenhoven B, &o'»'ter M. Pri'-opriratur;
3unadotrup'n-releasmg hcrmone analngu
1
: hetT'ip hyprtprertnmy
or myomectomy for uienne fibroids {CKnrang RevifliVj. In: T!ts
Gnchrfi.'jp Librzry Issue? UxtoriJ: Update Software 1999
Rein MS. Powell WL. Walters FC etal Cylogenerlc
abncrmalitle^ Ir, uterine myoniri^ are associated with myoma
size. M
e r 10
Endometriosis and

adenomyosis
Introductmn
and
auhfcill
lily
Symptoms
Trealmenl
Adenomvo&is
OVERVIEW
Momelrlosls
remains a
cnallenglng
condition
tor
clinicians
and
palieirts
aJike.
Difficul^ES
exist
In
relationship
lo ti>j)l<inalion
of rt& aetiology, path-ophyslolo^y and piogr^sion and IQ rt& iBCognltion, holh from symptoms and tfendoscopy Similar problems
In delErmming v;hoand '»hen to treat and lOr^hoviJang once Inn diagnosis has betn made
Endonietrinfiis
is
must
iiinply
defined

as
tlie
of
cndomenial
sucFaiie
ciiilhtlium
and/or
(he
pres-
ence
of
endumi'lnal
glands
and
*,rramji
oulwdt
the
lining
of
tlie
uterine
cavity.
One
of the
first
definite
dtscriptioiis
ot
endnmetrioiis
-i& a

specific
clinical
condition was by Sampson in 1921.
Endomelriojjj
n
c?ne
ot the
cnninioncsl
j^^naccologicjl cnndilions. It haii been
thai between 111 and 15 pf r i;enl of women prcwnlmg
with
gynaecologies] ivmpt<irns
ha^e
the
condi(ion.
This
estimate
of
prevalence
LS
based
on
identifying
Lesions 9t laparoscopy unJ^rtskcn for pain or investj-
gat»n of subfcrtility. Rather coiifustnglv, ihc tondi-
u
also sometime*.
MJCCI
m
asyTuptomatic

womeiij
di thctimeof Japaroscopk ateriUzalion.
ncal
du^n^sL
is
usually
m.uJe
follow
ing the
observar.ir»ji of haemorrhagic nr hi
1
In
ikcpchicpentoneaJ or the berosal aurlace of
. - - L."- •"• '-r v •.•"•• M-naiJ, [01
example 2-3 nun. nr can be txLrnbivt;, in aumc caics
obliterating tlie imrnirfl analum;' af the
pelvis, '[\KK cilwpic. cEdumetria] tissues, respond in
varying
degrees
lo
Qinlimcal
changes
in
ovarian
hnr
monci.
Unlike
normal endornelrium,
thc>
r

do not
li^'e
an
ordered
bluud
supply,
hut
tlieie
nan in
-growth
of new
capillaries,
Ci'dkal
bk'edingciin
occdi'wfthin,
and Irorn, the endonietriotk deposit and thib ce-n-
iriLnilv.^ lo a local intUmmatary readic-n. With, healing
and subsequcn! fibiosia. overlying peritonejl damagl
will
lead
to
adhesions
bcl^cc-n
as&ociattd
oigans.
Ovarian implants lead to the foriTijlion ol \hycoJak
q?s.ts or endomciriomai,. There is. theiefove a spen-
tnim
of
appearances

Ih^l
reflect
the
stage
in the euo
lution
of the
condition
aL
™liii h
Ihe
parient
is
seen.
Path agenesis
It is nnt known why some women acquire this, dis-
ease. Its perai.stence dud spread are dependent on the
ivihial
reaction
ofsteroid
hormones
Irom
the
ovanes.
P Understanding Ih
The precise aetiology Dig
Sevprar Ihecn-ES e*lst to (
win ch pndnmelnosis dew
e'-lfJence In support each
ffieury can expldin

In ah triKsites IB
It
hasten
suggested
Iha
and lisgje wllhin d
subsequent un plantation i:
animals. oxpe ri mental end
placenibn; nt mendruaJfli
l cavity, Eudomel
with
1
associated
tract, eaa tin-p. obstruction i
menstrual fluid, lending cii
Cue
Ionic
epithelium
Ira*
There Is a common origin I
duct. th? peritoneal cells ar
UwipruDuggdtJiai theggc
tack to Ihtiir pnnilJrfti origi
Hidomstrlal
cells. Tftls
Irai
calls osy be due
K yet Udid enilllau
1
uterine cndumetrmm or rfw

y irritation.
bclors
ftiay
^Jier
Jfte
Ber la o'evKlo
ncreased incidence m||rsl-«
•ilhthedisorderind
raciaFi
•eiflence ^monysl unentgl i
•i ivampn ol
Vascular and lymplialic spn
and lymphatic ema
fe Joints, skin, tfdr'ey and &•
Tliere Is dlnost ceMandy an
•:
ID Ihe killy deuglopEnl
Palh agenesis 111
P Understanding Itie paHiophysiolcgy
Endometrlosis remains unknown
explain
the
OPOCBSS
through
whi::l]eneuinelrioi>i5de.'elup3 and the re is clinical
evidence
to
support
each
ot

these
coni^pts
However,,^
single theory ran explain ttie l
in all the sites i • n i-i|
Menstrual regiirgllatlan and implantation
It Has been suggp?tedthatendc>mehQ&is results t'timtha
relrourade
merslruBl
regurglHlldii
ol
viable
endomenlal
glands andtissuettithmthe msn&trual fluid and
subsequent impUn:atipr urithe pen-oneal surface In
animals. experimental flndum*trsosi& can: be induced by
placemen! of menslrL^llluld 01 endonietrlal tissue In the
peritoneal cavity Cndiimet'iosi^ is also cnmmonly found
in worn tn with assorted abnorimlrties of Bie gen ltd
tract, causing obstruction to tie vaginal outflow of
menstrual fluid lending credence to this theory.
Cndmmc epithelium
T!" ere is a common origin for ITie Mils I in in; the Miilleriari
duct, the perilc-nedl cellE, dnd the cells of the nva
r
y It baB
been
proposed
tnal
thg^c cells

(i
ncergoce-diffarentiali
on
back ID their primitive origin and Ihen transform info
endUrriBtnal cells
Tlli:.
transformation
iitg
endometnal
cells
may be due to
hormonal
sl'muli
ol
ovailan
oilgiii
by
as vet
unidcnfiJind
chenol
sjbslartces
llbsrated
from
jlarine ^ndnmetrium ur those produced from
indasr.matory Irritation.
.en el ic and immurmlDgical lactars
Itha^bee^i suggested flial gen ttic: and immunolog cal
facto r&mavairartha^u^apilbiiirf'oi a woman and allow
tier
to

dei/elcp
endDmetnosis
Thpfe
apoears
tote
an
incrta^eC inside nue in first-dtgree relatives
wlh ftie disorder and racial diff&rentK, with
meiden^a among*,! onnnial v onen and 3 low
in vjonten nl Atra-Canljbefln
•;cularand lymphatic
Vascular and lymphatii: e^bokzatlon tod' slant sites Eias
been demonstrated and explains iher^refindlngsot
endnmgtnosis
In
sligs
outside
the
p^rltorr^il
cavity.
Tills
•ill
E'pPairifoci
in
sites uutsidethe peritnneal cavity, such"
B joints. 5kin, klonay and lung.
TTiere
is
aliiost
certamlv

an
int?racnon bet'-'eenone
ar '
«ure
uf
these
tlieuretitdl
pru!K5&s3
ID
a'lart
Hie
8e«lopnent
and
^ubsaGuen' growth
of
Ktoplc
Kiidometrlal
lo the fully do
1
/? oped endonielnotic lesion.
it i^ round almost esclu^iv'ely in women in ihe
reproductive age gioiip with lunctfjning ovari^;*. It
can also be mainliiiiKxl in 'Mniicn \vho h-ivt Lmdcr-
^unc oophorecTomy but .ire then given exogenous
hormone replacement treatment. Tt has been sug-
gested lhat the frequency ol this disease hdi increased
Id recenl years^ and factors sucli an environ menial
]>i>lljti[>i]
with
diovin^

have
been
implicated
on the
basis of primate studies. Howevi:r, another view K
that the apparent intrwic mA\ reflect ihe greater- use
•rt diagnostic laparoscopy to investigate pain symp-
toms and the scceptancc ol the more subtle iippciir-
ancciCtfLndckmciriuiiirtii
viewed endoscopicaLly. lliere
seenis to be no a&so^iitinn henveen the extent of the
disease process «een at lapjiosaipy and the patlflflfa
age 01 syniptomatolog;
1
.
Histological subtypes
tt is possible to link a numbei ol histological subtypes
of cndcunctnotic depoaits, spedfit
LipartnLup^ -mil a v.irKii nf rnorplioUijjiLal
nenfs to the presence of steroid receptors and honnonai
responsiveness in teims of piolifrrativc and icavtor^
change in ccdation&hip to yv^risin steroid hormone
stimulation. These ares tun mjri7ed in'lable 10.1.
FriT implants
'Ilies-e
have
j
polypoidal
cauliflower
lil«

striicturc
and grow along the surface orcovei acyMic structuie.
They are. characterized
by
lh<:
preb^nw
at j
burffice
epithelium siipiKirtedbvendometriaJstromj. Endome-
trial glands may be pieseut m an identifiable furm
01 may he
absent. Cjcliial
chants
i^ilhbulh
irt-tretory
JiffHejitiation and menstrual bleeding h.ive been
observed in such lesions fFig 10.1) These lesions are
highly
raspodsfrvelo
alterations
in
cKj&LrugenMnetioni
hcntL- Ihcv^re^er)
1
sensitive to hormonal su|>|>ressive
therapies
Fndowd implants
At th[s next stage of development the implanl has
become covered with a iurface layer of peritoneum
anrl thus located within tissue or with in partolafiec-

gvowmg lesion. These ki.[cm& will present ai Wtdge-
4iapcd otensionb of itroma irarnificationj, often
deep in local libim: planes connecting lesions with
one another. In a minority of lesions there are clear-cut
\ ' EndarnelriDsIs and adenorrwDsis
'Ihbli; 10.1 Eodomctrifl] deposits - correlation belm-cu hiitological, morphological and functional actjvitv
Histologies! subtype
Free
Enclosed
Healed
Hormonal
Lapuroscopic .appearance
ix
1
epithelmnij
glands and struma
Glands and slroma
only
Prulirbrative, secretory
and in eni [ [IM! changes
;, variable
Secretory change
No menstruation
rJu response
liaemorrhagic vesicle/bleb
Papule and Hater; nodule
While nodule or flattened
fibre li
3 <ajFuDkflredt
repre&enl a Isss active farm

are jnactuffi with no active 6
Coping hi 19&3, Parthenon
'5
•x>r-tx /a%J
W^HMF
Flgore 10.1 (a) fad lesion on senLuiiBum fsj High-power section of pentonflum with red lesions. Gland lined •.viifumdometnal-
Ilke
Vallum
and
surrawdri
ty riTDtna
£^reroryacnvnynot5E«n(bi'ip^takenond3yl5ofa'i:lt)
(Sn'jrce
An
Atlas
of
Enfiomeinosls. Shaw Robert w. Copyright 1993, Partbenpn Publishlnrj Grdup )
Figure 1D.2 iaj Eflen^ivt ndtmorr-iaDir lesions indic^live of aciivR, symplumalic Ji^ease ft) Biopsy from active leamns on
day 24ofrjyds.Hi&lcluyy Eboi^n^dematou^ci:i]ritctivetipi^u?,b^rnQ^iderinHadenm
*tffi
SKrelory
acdvlrjr. (Source
An
Attes
of
Endonatrlosls Sba-'
Robert
W.
Copyright
1933 Parthenon

Publishing
Group)
changes in rupun&e 10 the menstruaf cycle, with ovarian cycle^ The lefiioni react in a similar way h
evidence 01' prolifeMii''t and secretory change and ba^al endonii'lrmniand sudi lesiom are onli likely i
menstrual bleeding Hawevn, capillary and venous be partly responsive to a hormone i
dilatation i, i,een during u- lulcal phase of the (Fig. 10.2).
Heated
have the
Inin
J^
31
by ^mjll nurnbers of
cunneLilin: ti^sut. This.
IIS.S.LK; and [he encf^iiUK
the amounts i>fscartisii
*n hormonal
K a s-upt'iJiciaJ funn uii
*morei£;\c]e form
3*
&>
seen wj|h
*hl red vehicles or blue
ig. 10.3) 6uehhdcinoi
with sidheiion
relevance- wh(
iff
rFiu
ovaries,
sii
iri

ih.L
The word eruluniettitii
emotic for chocolate) i
lioin
(hn."
cliar-nto
jiloiireil
tonlenl
of
the
q
bed liy
Jree
Jjndomelri
Mmil.ir lo i
vei, in jrunv uiskint
of an endonietnoma
only by thkkcned fib
id function^ activity
agic vesicle'blcb
and I later) nodule
Figuriin 3 fp.
pprcsenr a less
are-
1
ntrtive with
Scpynght 1993
Punk&rgd
blue-brack
lesion

with
surrounding
wh-te
iiCrou^,
pidgin?
-
da^kdl
>u«der-biim"
lesion
but may
achu* lorm ol dlseaeB ib) High-power biopsy ul lesion showing fibrous tissue and en domain one glands which
nn active Needing (biopsy taken on day 21 ol cycle). (Source: An Mas ol Enacmelnosis. Shaw, Robert W.
Parthenon Publishing Group J
^ * ¥t
y
•' •ijff*'
•MMied wiHiendomelrial-
An Atlas of
Healed lesions
These
hrf^c
ihe
feature
of
iv&ticalK
dilated
glandi
containing a thin glandular epithelium supported
bv small numbers. at stromal cells .surrounded by
Jmneiln'e

ti&sue.
Th[i absence
of
function
aJ
stromal
os&ue and the en closure o-f Iht implant by increasing
:he amounts of scar tissue make ihe
to hormonal ilimuli.
mvarittn endometriosis
Endoinetri^sis. involving (lie
»j a SuperficiaJ form with baemorrlupic lesions ov in
a nmrcicvcrc form us iin<:ndoi,v:dhjcmoiiha^ic cyjt.
The superficial les-L^iis, haw the varying appear-
ances seen with in\f>lve men I of the peritoneum They
mmmonli'priicnt as superficial haernniihagic lesions
and red vesicles or blue-black 'puwtk-r-burn Itsiuns
(Fig.
1(1.3)
Such
hatmorrh^gjckiioot
are
commonlj
^'ith adhesion lonnation. Adliesiona are of
relevance when Lbcy involvL- Iht p^blcrior
aspect of the nvariesj s^ince they [hen rapidly le.id lo
fixation within the ovanan toss-i (Fig 10.4]
The ivurd endonn'trioma is used to describe cndo-
•iotic jnr choi;n-late| cvstfl of the ovary,
r

lhe iwrnt
rroni the characteristic dark bimvii chonolate-
iuni ol thi
1
cpi. lliitologiciji'j'aluation of
ndametrioim
shows
there
is a
wide vdrklion
in (he
;
pesence
of
endumetrioik
li^s-ue.
'Ihe
CY*(
wall
J.STI
(m
by tree cndomctrial tissue, hisrologically and
ioiirilly wmilar 10 ibwl of cndomtlrial lining,
vever, m many instances of the long standing pres-
jf an endometrionia, the q\st waJl becomes cov-
only
bv
thickened fibrotic
K'LKLLVC
tisiiLic,

ivith
no
features of glandular
Figure 1D.4 EmlDmetnoma en left ovary '"lib
descending colon (Source: ^AW
W Copyright 1 993. Pdrthenun Publishing
EndornL'tnomji arc- thought to be formed from
lesions that commence on the outer surface of the
ovary As they grow larger, theie k inversion of [be
ovpniin coitiji and, with increasing inflammatory
reaction at the site of inversion, this becomes occluded
The inverted ovarian cortes slowly becomes distended
and tilled with the 'chocolate' fluid from repeated
'mi'nstiual bleeds'. Leakage from the cyst wall kadi
commonly in adhesion formation around the endo-
mecnoniiis, particularly on the posterior surface of
ihe o^'jri
1
within ihe ovarian fossa or lo iht
as pect of the broad liga men I.
Patients with endometrlosis have extremely variable
symptunii. Some aymplonii
nuv
vjrjf
depending
un
[he site of the eclopicendoinetrial lesion, but theie i.q
114 End Dm Bin DS Is and a dene my as is
Table 10.2 Symptoms of endojnelrio&is in
relationship [n site of lesion

Site
Symptoms
reproductive Dsymen o rrboea
Lower abdominal and
pctni. pain
Dyspareunia
Rupture/toision
endomelriuma
Low back pain
Infertility
Uiinarv [racl
Gaatrointe&tlna] tract
Surgical scans/
umbilicus
Lung
Cyclical liaematuria/dysuria
Ureteric obstruction
Q'clieal rcclal Weeding
Obstruction
Cyclical pain and bleeding
Cyclical haemoptysis.
I Inemopncumothura}:
3 lack of correlation between the apparent extent of
ihe disease, as fudged laparoscopically, and the intensity
of symptoms. Indeed > the disease may be a coinadenlal
finding during open surgery or during inu'sligalion
of a patient complaining nf infertility". It may be
I'Ouible to relate the variety of symptoms in patients
wlcli endomeiriosis to the siting of Th« deposiTs (aoiii-
marized in Tahle 10 1], hut otten there is. little direct

correlation lo more spedflc siting of lesions.
It can be seen (hut many ol tbest svmptoms are
shared hya numl>er tif other en mm on gynaecological
conditions,
or
disorders
of
urogenital
or
gastro-
intestinal
iplrm
origin,
Thib
cro&s-oiTr
of
svmptoms
means, that many patients with eiidoinelriosis have a
delay from the tune ol onset of symptoms 'n the lime
ofdidgnosis
ol the
disorder.
They
may
well
have
heen
orated for oilier conditions prior to its, definitive
No one symptom is. [ntally predictive of
one symptom is highly suggestive,

Uspasmodicd^menorrhoea, particularly if severe
llo warrant time nffv^rkandi if unresnonsive To
s II tins symptom is also associated
with pain on poitnunstrual days, pelvic pain
oni ihe ode or deep piin ai inltrtour^ [tlixp dvs-
pareunia), this should further heighten the suspicion
ol endometnosis. The occurrence ot abnormal cycli-
cal UliXtling dL tht time of menstruation, from die
rectum, bladder or unihilicufl, is strongly •iuggestiue
ol the presence of the disease. Heavy penods arc
probably [hi
1
1
iiuM
1
rather than
ancifcct
of
endomctno-
sis>
as
esposute
to
menstrual
flow is the
main
risk
tactoi for developing the condition.
Physical examination
is su^^eitt^ by lh<; ilinkai findings 01;

vaginal evamination of thickening or nodularity of
the uleiosacral ligaments, tenderness In the pouch ot
Doughs, an ovarian masb or mabsci, and a fixed ri'lro-
verted uterns. However pelvic tenderness alone is
non-specific, and differential diagnoses foi lestiicled
mobility of (he titeius include chionic pelvic inflam-
matory disease {rare in Ihe UK) and uterinu, ovarijn
or ceivical nialignanq'- Tn these conditions, other
sngge&lni: features arc usually present. Specific diag-
nosis requires visualiiilion of thi
1
poriloneal c«vii|
and biopsy of lesions in uncertain cdses. either at
laparoscopy or laparotomy.
Nan-invasive tests
CA 125 levels
CA 125 is a ^lycoprotei n expressed by some epithelij
cells of coclomic origm. Serum levels are raised in a
significant proportion of'patKnts with ovarian epithe-
lial carcinoma. Tt is noted that patients- with severe
tndomctnosis may alsfl ha\-e elevated CA 125 levels
Liul
ihtsi
1
arc not to
comparable
to
those
in
patients

with ovarian cancer. In Chose i^ilh elevated CA 125.
levels, otten lall daring treatment, and rists in CA 1251
correlate
wdl
\.ilh
RXUI
mice
of
disease.
However, in Ihe inajorik of individuals., mi'siaure-
nie.nl of CA 125 alone cannoi be diagnostic of tht
presence ol endomelriosis
Ultrasound
l^llrasound is of limited value in the diagnosis of
endometriosis, other ihanforl
cysts that might lurn out lo be
A characteristlc feature of an endomettioma is.
Endametriosis and
»jlhe
(H-esence
of a
few
rendei- a patient &
EndomeLrkisis and sublerlilily 1 •
i. pain through-
deep dys-
the suspicion
nee of abnormal cvcli-
iHKtnidtion, irom the
is strongly suggestive

at- Heavy periods arc
M effect ufendometrio-
Iflow is 'tie main risk
Slum
- the cliniul fin dings on
or nodulsrity of
in
th<j
pouch
of
and a fixed retro-
ric letidemesb <done is
diagno&ea for restricted
c chronic pelvic inflam-
TC- anil uterine, ovarian
ibcse conditions* other
y present. Specific iliag-
of the peritoneal cavity
Kcrtain caseb, either al
•HaedbysorncepilVielial
HIM levels are raised in J
fenrs with ovarian epilhe-
rhaf patienlb. willi severe
* elevated CA 121 levels
rahle to thow? in patients
K with elevated CA 125,
and liscb i" CA 125
of individuals, nuM sure-
dim be diagnostic ot the
in the diagnosis -4

i die assen.nie nt of ovarian
lo be eiidomelriomata.
f an eiidomctrioma is «
c coileition of low-Joel
Echoes within an nvarijo cvst,
magnetic resonance imaging
Magnelit resoiunt^ inidging (MRI) puttniiallv offerj
significant gains in tne imaging of endometriosis
ultrasound when there arc o\anan
or invsision uf surrounding urj/ani &iuh t& the
s hladder or reiitovaginal septum. The image
qiiiditycan be useful toi planning technicallydiffkulI
^urj^fry. 1 hiwyvcr, in ihe m^ijoritv of p;ilicnl&, MRI ij
of little lienefit, as peritone.il deposilwre onJ^ a feis
millimetres in diameter and are nol well seen.
Litparowpy
l^ipdrobcupy rcmaim the 'gold standaid' means of
diagnosing this i-Ondilion, Ab iho^vn in Figures 10.1
and 111.2, ihe laparoscnpk features of endometriotii:
ditquiie 'nnable, and inexperienced Japaro-
may miss lesions unless they are very exten-
sive-, fail to reaiftni/e aiypkal lesions, jnd In Tti^ny
because of a failure lo dn an adequate visualization of
ihe whole of the pelvis, pjrlicukrly the ovarian fb&sa.
Laparnscopy allows direct visuali?^!ion of endomelri-
olic lesions and the possibility nf biopsy of snspicinus
*rtj& and" alsu blaming of the disease m terms of
ifre exlcnl of ddhciioni unil the number and size of
lesions. It also allows for concurrent therapy al the
ume ollapriroirfopvin the roirn ofdiatheiniy or laser

In selected
TiblelO.3 Infertility u
mechanisms
oaig- passible
Endometriosis and sublerlilily
> i% estimated lh-i( between 30 <md 40 per tent of
fBdents with endomelnnsis complain of difficulty in
ir. In many patients there is a mukifactorml
^ihogcnesis to thissublertihiv. It has yet to be shown
fcowihe presence of a few small endometrioticdepo&ils
•iighl render a patient sublerlile. Tn tlie more severe
*a»W'b
of
endomttrio&i&
there
is
commonlv anatomical
•bflortio 11, with perJ-ddnexal adhesions and deslruction
it ovarian lissue when endomelnonias develop
knee
a
nioic
readily explainable rektionship isiippar-
V- A number of possible and. variable mechanibms
b<e been postulated lo connect mild endnnietriosis
••h Subfertility. These vary from endocrine disorders
fcdudinji ano^ulalion, aJtcrcd prolactm beiretion
•hi
Iuteini7ed
nnvuptuved

follicle
syndrome,
to
dis-
^ners
ot
sperm
or
oncyle
tn net ion
(Table
111.3).
Ovaiiiin tiinction
Tubal fnnetion
Coic.ll function
Sperm hinclinn
EVrK pregnancy
rail u re
by
prostaglandins
Ooc)'te maturation delects
Endou mopa ihieb
Luldni^ed iitirupmred
follicle syndi'ome
Altered piolactm rcleabe
Anovuldlion
Impaired llmbrial ootyle
pkk-up
Alteied tubal mobihly
Deep dysparenma reduced

coilal frequency
Antibodies causing
inailivalion
b'rostaplandin induced
Immune reaction
Luteal phase deficiency
Currently there is no simple explanation ol how
mildendometnoiJb may prevent conceplion
For this reason many ini'ejiig-ilors ^vould
lh<: bi'nefil of any form of medial or surgical treat-
ment in such cases. Clearly, if, aparl fiom hei subfer-
tihtv the patient albo has symptoms s>&ocLiled i^illl
endomelnLnis, appropriate therapy is indicated. How-
ever, il is accepted lhal endometriosis is a disease that
tends to peisist and often progress i\uh lime. There is
iin argument that oflering therapy al sin early .siage
m,iy prevent further progression nf the Disease, the
end result ot which may well be mechanical disrup-
tion
to
tubal-ov^rian
funclkm.
I'Lir
these
reasons,
endometriosis involving the posterior aspect of the
ovai v and the ovarian fossa is often treated a! an eariv
stage, whereas endometrLosis otXurring only on the
ulerobacr^l
ligamenls

may
well
be
left
untrated.
Froni the balance ot evidence, cundusians have
been drawn thai, aparl from medianical damage,
endomelriosis does
nol
canse
subrertilitv.
This
iie^'
his been substantiated by the failure of mcdkal thera-
pies in placebo-conlrolled trials to improve conception
rales, lluwiver, this widely held viewpoint may well
be brought inly question following publication of the
findings from a CanadJan moitLcantra atudy in which
surgical flaparoscopid abldlion uf deposits, was; en in-
pareil wilh no intervention. Surgical ileslruclion did
improve Cumulative pregnancy rates in this study* bul
further
confirmatory
tridk
^re
Awaited.
With
regard
to hormonal Iherapy, the evidence is very clear thiit
this treatment doi'i no! rmpiove subsequent fertility.

Treatment
Patients with endomelriosisare often difficult to treat,
nul on!;, from ii physical poinl of view, but also often
because of diboaated psychological issues. For iume
patients the label of eiulomctnoiis in itself may create
ill own problems, since it is known to be a recurrent
disorder throughout the whole of reproductive life.
Whilst there is no ilandard lormula for treatment, nor
indeed a cure, i( is iniportanl to tailor treatment for
rhe individual according to her age, symptoms, extent
ol' die diseuse and her desire I'oi future childbearing.
Problems also arise when minimal endometiiosis is
detected in a patient presenting wiill pain and there is
veal uncertainty a& to whether the condition ib coinci-
dental 01 causal. In ibii bituanon a kill explanation of
llu: j&bociated diagnostic uncertainty LS required.
Drug
Analgesics
Non-fitffrttidal anti-inflammatory drugs \NSAIDs) are
potent anal&eski and are very helpful in reducing the
.seventy of dysmenorrhoea and pelvic pain HOIM^IT,
thev have no specific impacl vn ihe disease and its
nrogreibiim and hence their use is for svmplom con-
trol. There may be additional benefit in combining
thost agents with paracetamol or codeine, so as to avoid
the main adverse effect of ViAIUs which is gabtrom-
testmal upset.
Combinfd oral tvtiftaceptive agents
Orjl contraceptive agenls jrc known to reduce the
severity of dysmenonhoea and menstrual blood loss

in many paiienis 'iliey may be of some beneGi, but
anf often of Jittle help when given in the standard
manner vi ili rcgiJarrnonlhlywilh'frawal bleeds. Two
iir three pdcki of pills taken without a break maybe
beneficial in avoiding ihe exacerbation ot syinptoms
asbociated with menstruation. EApLuution dial miss-
ing a
withdrawal bleed
is not
harm
fnl is.
often
n^Jed,
lla ttazol/gest rino ne
Panazol and gestunone are hormonal^ ovarian ^np-
pressive, mplical treatments comparable in their effect
ol reducing the severity of iymptomb tor endonsetrio-
fiis. Danazol is given En a dose of betwucn 400 and
JWII ing,
daily
and
geitunone
in a
dn.se
of 2.5
nip,
li^iee
weekly.
In
most

irlSlniitL
1
:*
the
drugb.
are
well
tolerated,
I?n1 many women do exiierien^e diidrogenic bide
ffFects^
c.g, weight gain, greasy
skin
and
acne.
The
drugs are normally gmrn Id courses ot between 3 and
o months. In longer-term ad numeration oi the drugs
[bviVDifly
be
alterations
in
li[>id
|>m
files
or
liver
func-
lion, which nctd to be monitoied. Prescrihinj; of
daniizol has recently been reblncled owin^ to a pnssi-
I'le dibociation with ovarian cancer,

Progestogens
Synthetic progestogens such dS nicdroAyprugeiteronc
acetate and ihdrogcsterone have been given un J
Continuous h.isis 10 produce pseu.do-decidualizal.inn
of the endornetrium and comparable change*, in
umil omi'tnotic lesions. The dose iifagtntb required to
he effective is quite high, and side effects, including
breakthrough bleeding,, weight gain, fluid letention
and weight changes, are not uncommon,
(Jonadotrophin releasing hormone agoniits. {GnftH-
A} -ire ab crfcctive as danarnl in relieving (he icvcrii^
jiidwrnptoms of (udomctnosis and differ only in their
bide cfrects. These drugi induce a state ot \typo-
gonadotrophic hypogonadism or pseudo-menopause
with low circulating levels nf nestrogen. Side effrcb
include symptorns hccn at the menopause, in particular
hol fliibhei and night sweats. [Je^iilc thebe bide etfcds.
the drags are weL toleiated and they Ivc l^cume
Cbtabhshed agent.s in ihe treatment of endometriosii
They are av-aiJable as multiple, daily-administered.
intrii
nasal
spi ays or as
slow-
rele^edtpot
formulation*.
each lasting for 1 month or more Apart from ihe
symptomatic side effects described above, the Uw
circulalin^ oebtrogcn le\
r

els can affecl bonu
bnlism in ways comparable to those seen at the
menopause Therefore, with continuing long-term
there cdn be reduction in bone mineral density,
ranst acutely in the
spme Hone loss of sor
month count ot tna
palicnts tiiis is readil
returns on ceasing iht
tion of loiv-doH: horm
along with the dnRH
back' iherapy, niayoflt
effects of oestrogen d
ahuut the long-term r
mem ib bn tar lacking,
Surgical treatment
Conservative mrger
Liparosconic surgery
abdominal lasers has be
ol management of ei
simpler and >aler to .
lesionb witli dialhtnrn/
otdorifetriotic cyflts can
inner cysj ^.11 or linm|
me Ubci". In many inwai
may still be necessary,
Deduced the need tor opn
times, and this allows, p
Hich time as definitives
Definitive furgcry

Whece there are severe
Qae nr in women whos
Wvc surgery for the reli
• oflcn necessary. Thi
fcmy and bilateral :
wmovaf of [he o^'anes
•Qnepindutlionisbei
relief.
Par»
HRT subsequen
mi ol recurrence, th(
i»n dderred for -i per
pardcularl} when acliw
•nt at the lime of lapai
•*• a period nf^monl
Definite surgery is a
jmetriolii ijstb ant
who ha ve deep-?
or bladder, Em
of which we still hi
Adenomyosis
hormone agonists
•moiie agonists (GnRH-
1 in reliving the seventy
HSand differ on]i
1
in their
nduee a bta.te of hypo-
id or pseu do-menopause
of oestrogen- Side effect

c menopause, in. particular
. Despite these side effect^
d and thev nave become
atment nf endumetiiosii
duple, dailv-admimsiered
idca.se depol formuLiULio^
or more, 'ipart from ihe
icsctibed above, the low
i on aifett hone ineH-
m mobc seen at the natural
i continuing long-termiue
june mineral density, se™
most acutely in the trjbeeukr bone of the lumbar
spine. Done lossnf some :• per cerH tun oicur uvcra t>-
motl[h iUur>e ol treatment, but Ini the inajorily of
patients [his is readily replaced as ovarian function
returns nn ceasinp the drug iherapv. The jdminibtra-
tinn of low-dose hoimone replacement therapy (HRT)
along with [he GnRII-A analogues, the so-called 'add
back' therapy, may offer ,1 way uf preventing the adverse
effects of oestrogen deficiency, atlhough information
ahouE (he long-term, rebults of this appmacb in trej[-
ment is so far lacking.
Surgical treatment
Conservative surgery
•paroscopjc
surgery with techniques such
as.
intra-
abdominal lasers, has become (he swndard for the surgi-

cal management of endnmetriosis, It is now much
ampler ;md bafcr to eradicate visible endometriotic-
lesions with di*(h.ermy> CO-, or KTP laseis. Likewise,
rndometriotic cysts, can be droned and opened and the
inner cysl
iv^U
or
lining destroyed
and
vaporized
v-'ilh
the laser In many insldnecb.beeauw: of the severe adhe
Hve disease found with ei]doine[riom,i>, open surgery
rn.iy slill be necessary Conservative approaches ha\e
reduced iheni'i'dlui open surgery with its. Innp recovery
times,
and
tliifi
allows
padcnlb^
to
delay laeatment until
»"h time as definitive s.urgerj~ may become
iere there are severe sycnploms or progitiiivt dis-
corm i^omtn whose lanulies. are complete, defin-
e s-ur^erv for ( he relief of dysmenorrhoea and pain
often necessary. This, [^kes (he form etf hystcret-
y and bilatcial salpingo-onphoreclomy. The
ova] of ihe entries and subsequent ovarian hnr-
ne production is beneficial in achieving long term

ptom relief Paradox itdllv, &uth patients can
f ive I1RT subsequent to surgery. To minimise the
nf recurrence, ihe commencement of HRT is
n deferred for a peri od of time following surgery
rticularlv when active disease was found to be pre-
rt al ihe lime of lapaiotomy, and [his delay is typi-
a period of 6 months or more.
fcumtivc surgery is also required for Idrge- dJIii'rcnL
onietrioui evs(b and for the small prnportion of
ents who have deep-s<v3ld endometriosis m^-ohang
tt.nvel ni bladder. Endometriosis ihua remamb 3 dis-
H of which we Slill have little understanding and, at
present, little ho|>e of a permftnenl mrc other than
definitive surgeiy in the form of pelvic cledran« New
In'rtimeni op[ioru, both medical and laparnscnpic
surgery, have expanded the potentiaJ lor delay in
surgery, hut for most sufferers the disease remains one
ol repent iccuirentes [broughouttlieir reproductive life.
Arlenomyosis
Adeiioinyosis is often intorrecrly termed mteinal
Lndometnosis because of the histolopical fealnre^ of
ih': duordfir in which endometrial glands are found
deep vrithiii IJie myomolriLim. .'Vik'nomyosis is. increas-
ingly being viewed as a sep.irate pnilhologiij.1 entity
alfectinga ditterent population of patients willi an as
vet unknown ,in<l ilifferent aetiology.
Patient; witli adenomyosis are iiiuallj multipiiious
and diagno^d in theii late [birties or early forties.
lliei
1

prisinl widi matasingly se\
r
ere secondary
SpASmudit ilybmenorrhuca and increased menstrual
blood loss finenorrhagia) hxaminalitm uf patienlb
may be Libcii.il with the hndings most often of j bulky
andsome[miestendcr ulcrub, pariicularlyil examined
peiimen^tnially.Ultra^oundeTainiiidlioji of Ihc uterus
may be helpful on occasions when adenomyosis is par-
ticularly
mrfrkenil
or
localized
to one
area. Tlien ultra-
sound may show alterations of eehogemcit} within
the myometrium trom the localised, haemorrhaye-
fi!led>dis<endeil enilomelnalgkndb. In some instances
where ihere is il very lucali^tl arej ol adenomyosis, this
may give an irregular nodular developmi'nl wilhin
the uterus, veri sunilai to that ol uterine fibroids. MKI
provides- excellent rm;i^es af the myometrium, endo-
nietrium and aieas of adenomyosis and j& now the
investigation of choice.
Given Ihe practical difficulty m making the diagnosis
of adenonivosis preOpcKitivd;', eon&eriptivc burgcn
r
and medical treatments are sn Far poorly develo£*d-
ln gcniial, any treatment that mduces amenorrhoea will
he helpful ,is it «ill relieve pain and exee&sive bleeding

Effective agents such as dana?ol, gestrinone and.
CinKll-A used m the treatment ol cndomftrioas
^Isu be bcneriaal fbr this condition. On ccasn_
ment, however, [he sympioni.s rapidh' return in Alt
majority nl patients, and hysterectomv remains the only
dellniiivc
(re<iirncm.
\Vbere
well-locafccd
cijnds
of
adenomyosis
can he
identified,
within
the
nnvnetnurn,
there
is the
pntential
for
lapainscopic
laser
au^en.
ind
sonic reports of bcndil have appeared in ihf literature.
I ' Endcnietriosis and ad&noinyosis
C "I a
Qne of the commonest gynaecological
conditions and at present alfee;s between 10 and 25 percent

ct women with symptoms of gynaecological unpin.
Growth of endomelnosis is oEstroqeri dependent.
End nmetnns is is assocla'edVhltntuuJl and ovarian damage
dridthe lormr.lion of .ndhesions and can com promise fertility
The commonest presenting symptoms other than infertility
are painful periods Jim dyspareuma
The typical penfoneal lesion Is described as c powder burn'
Tfiemedical treatment of endc-metriosis involves
suppressing oestrogen and progesterone levels To prevent
cyclical changes and includes treatment with piogestogans,
gestilnone or GnRH aganisfs
The MI
-Qical
treatment
of
endometrlos
is
i&eiflier
rn in
irridlly
invi.&ive using laparoscopic igchniques, or radical, wlthtolal
abdominal hvsrerectamyand bilateral
r
-a pmqn-nnphgifitfnmv.
Adenomyosis is a common mndifion, presentng with painful
pejiods and is co.Tirnon in women In their late thirties m
early
tones
Pathnlngy
Aye diEfnbiition o

Presentation
Diff-srential
Additional reading
Jaco&sonTZ, Barlow DH. Komnckx PR Olive D. FnrquharC.
Laparc"-ipic surgery tor sublerlihty )b:3ciafec with
endometrmsis [Corhnnc Msfhcdology Rp'lew} In: The
Lil/i3."/. Issue 4 Chicli ester. UK
Sampson
JA
Perforating hapmnfrlidciic (chocolate)
&y&t&
of the
O' aiV. AfCfi Surg 1321. 3 245-323
Sampson Jft. Pentoneal endametrujsis due ID menstrual
dissemination of ertdomfltnal tissue into the peritoneal ca"ity
An> J Qbsle! tjyttecQil927. t4:422-G9
OVERVIEW
tertian ovarian cybk ire i
gynecological cause of&
for
this
reason
in prpmcnopausiil women
manapernsnt sra ic etolud
inyDimger i"0mefl.
Ovarian tUfTioors may be
are cysm: The finding of :
tumours usually have
Palhotogy ;
_^^—

^^^^H
Physiological cysls
hich fonn in the ovary
de. Moil jrc asynipto
^vii. examiiiiiliun or i
ey may otcur in jny p
in i