Endometriosis and Adenomyosis MCQs

A female giving a history of sharp pain in lower abdomen, every month, 2 weeks before the menstruation suggests mittelschmerz as the diagnosis. Mittelschmerz is synonymous to painful ovulation. Pain is associated with rupture of ovarian follicle at the time of ovulation Ref. Dutta Gynae 4th/ed p 172, 5th/ed p 178

Ans, D. Hysterectomy Hysterectomy is the treatment of choice. Local resection can be tried in younger women in whom it is localized. Medical treatment oPtions are NSAIDS & hormonal therapy, though not much effective GnRH, danazole, Mirena IUCD for menorrhagea & pain.

Causes of secondary dysmenorrhea: PID Endometriosis Adenomyosis IUCD Uterine fibroid Polyps Cervical stenosis Congenital malformation of uterus like bicornuate uterus Management : Treatment of the underlying cause. Reference: Berek & Novak's gynecology 16th ed, p580

(B) Adenomyosis is a condition where there is ingrowth of endometrium (both gland + stroma) directly into the myometrium. Earlier it was called Endometriosis interna It is more common in Multiparous females(i.e.option a is correct). (A) Adenomyosis is more common in women who have had children, so it is not most common in nulliparous women. (C) Adenomyosis commonly presents with symptoms such as menorrhagia (heavy menstrual bleeding), dysmenorrhea (painful periods), and an enlarged uterus. 60 (D) Adenomyosis is more common in women who are in their 40-50years , so it is not typically associated with younger women. Reference: Shaw 15th/ed pp 474-5; Novak 15th/ed pp 484-5.

Endometriosis sometimes occurs in abdominal wall scars following operations on uterus or tubes and is known as scar endometriosis. Operations most likely to be followed by scar endometriosis : Hysterotomy Classical cesarean section Myomectomy Ventrofixation Following operations for section of fallopian tube Following operations for removal of pelvic endometriosis Episiotomy Ref. Jeffcoate 7th/ed p 371

“Deep penetrating endometriosis is a form of the disease which was described by Koninck’s group. These lesions can extend 10 mm or more down from the peritoneal surface and the deeper lesions appear to have a closer association with pain than infertility, whereas less deep lesions have a closer association with infertility than pain.” Reference: Williams Gynae 1st/ed p 230 Reference: Novak 14th/ed p 1144, 15th/ed p 512

Endometriosis is occurence of functioning endometrial tissue (glands + stroma) outside the uterine cavity. Whatever the initial genesis of endometriosis, its further development depends mainly on estrogen (Option “a”). It can occur anywhere in the body, Most common site being ovary (Option “d”). Can also involve lungs and pleura (Option “b”). In endometriosis the ovary contains tarry dark brown fluid (due to presence of blood pigments like hemosiderin) and cul de sac has yellow brown fluid. Clear fluid is not seen anywhere, So, Option “c” is incorrect. Reference: Shaw 15th/ed p 466.

Drugs used in the management of endometriosis Mnemonic - Proctor and Gamble Always Offer Good Deals Proctor –Progesterone -First line management → Injectable progestin-DMPA and → LNG-IUS → Oral progestins- continuous administration Gamble –GnRH analogue Always –Antiprogesterone-mifepristone Offer –OCP Good –Gestrinone Deals –Danazol Superficial peritoneal and ovarian implants may respond well to medical management but large endometriomas and extra pelvic endometriosis are unlikely to respond and will ultimately require surgical excision. Reference: Shaw 15th/ed pp 472-3; Novak 14th/ed pp 1164-9.