Endometriosis and Adenomyosis

I recently operated on a 28 year lady with both endometriosis stage III and with significant adenomyosis. Although endometriosis is a rather common condition in women especially those in there 30s and 40s who have few or no children, this was unusual in that here was a relatively young lady, getting married, in the best reproductive years of her life with extensive endometriosis and adenomyosis. Endometriosis is a generalised pelvic condition in which there are blood cysts scattered throughout the pelvis but mainly in the folds between the womb and the bladder in front and the rectum and intestines behind. There is also a predeliction for the ovaries as well. In stage III endometriosis, there are large blood cysts involving both ovaries and extensive adhesions of the surrounding structures. The disease acts almost like a cancer attaching and invading surrounding tissue although it is not malignant. It is simply distructive to the structures and can significantly affect her fertility. She presented with heavy irregular and painful periods. Very often there may be no symptoms other then infertility and found during investigation for such. In addition she had adenomyosis. This is blood cyst mixed together with a fibroid and is present and invades the muscle of the womb. Pain during the period comes from the bleeding from all these blood cysts. If the cysts are large they may even rupture during the period.

In her case I obviously had to be as conservative as possible. She was offered the alternatives of medication in the form of danazol for 9 months or a gnrh agonist lucrin. Both would induce a semi-menopausal state and allow the shrinkage of the cysts. This would however not be ideal as it would be impossible to shrink away the disease and cysts totally. She was therefore offered surgery as the better alternative followed by medication as the better choice.

Such extensive disease is unusual and requires careful considerate surgery to restore her fertility. Endometriosis and adenomyosis is thought to be an immune disorder and is related to backflow of menses through the fallopian tubes allowing the cells to implant on the pelvic structures. It should be suspected especially if periods get increasingly painful. Diagnosis early in stage I would prevent further progression with medication or use of laparoscopic laser surgery (key hole). Regular gynaecological checkups with ultrasound scanning from an early age is the key.