OG34.6 | Endometriosis-Adenomyosis Spectrum — Summary & Reflection

KEY TAKEAWAYS

Endometriosis is the presence of functional endometrial glands and stroma outside the uterine cavity. The most accepted pathogenetic mechanism is Sampson's retrograde menstruation theory. The ovary is the most commonly involved site (chocolate cysts/endometriomas); other key sites include the Pouch of Douglas and uterosacral ligaments. The classic clinical triad is secondary progressive dysmenorrhoea, deep dyspareunia, and subfertility. Diagnosis is confirmed by laparoscopy and histology (gold standard). Disease is staged rASRM I–IV (stage ≠ pain severity). Medical therapy — NSAIDs, COC, progestins (including dienogest), LNG-IUS, GnRH analogues + add-back — suppresses disease but does not cure it. Surgical options range from conservative (laparoscopic ablation, cystectomy) for fertility-desiring women to radical (THBSO) for severe refractory disease. Endometriosis accounts for ~30–40% of female infertility.

Adenomyosis is the presence of endometrial glands and stroma within the myometrium, producing a uniformly enlarged, soft, boggy, tender uterus. The dominant symptom is menorrhagia with secondary dysmenorrhoea, typically in multiparous women aged 35–50. Diagnosis is clinical + MRI (junctional zone >12 mm); histological confirmation is on the hysterectomy specimen. First-line medical treatment is LNG-IUS (up to 90% reduction in menstrual blood loss). GnRH analogues are used pre-operatively. Definitive treatment is hysterectomy (oophorectomy is not required).

Key distinctions: endometriosis — pain-dominant, ectopic peritoneal/ovarian, laparoscopy diagnoses; adenomyosis — bleeding-dominant, intramyometrial, MRI diagnoses. Both are oestrogen-dependent and hormonally managed, but the surgical endpoints differ.

REFLECT

Consider the 28-year-old teacher from the opening scenario. She waited 4 years before seeking help — a delay typical of endometriosis, where dysmenorrhoea is normalised. Now reflect: If you had seen her 3 years ago at age 25, presenting for the first time with worsening dysmenorrhoea and deep dyspareunia, what would your clinical approach have been? Would you have initiated COC empirically, or referred for laparoscopic evaluation? What factors — her fertility desire, pain severity, examination findings — would have tipped you towards surgical diagnosis versus medical suppression? Now consider the 35-year-old multipara in the second case. She has adenomyosis confirmed on MRI and wishes to avoid surgery if possible. What is your management plan — initial medical therapy, timeline for reassessment, and the threshold at which you would recommend hysterectomy? Connecting pathophysiology to patient preference and clinical decision-making is the core of gynaecological practice.