The many faces of Endometriosis

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Anastasia Curtis
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1 The many faces of Endometriosis Beryl Benacerraf M.D Harvard Medical School

2 What is Endometriosis? Endometriosis is defined as the presence of normal endometrial tissue occurring outside of the endometrial cavity. This tissue responds to cyclic hormonal changes resulting in localized bleeding, inflammation and adhesion formation.

3 Common sites of endometriosis Ovaries Uterine surface Peritoneum Uterosacral ligaments Cul de sac Bladder Bowel wall Scars in anterior abdominal wall Rare outside pelvis

4 Common sites of endometriosis McKinney et al., 2000.

5 How Common is Endometriosis? Prevalence in the general population is estimated at 10% of women. Present in up to 80% in patients with pelvic pain. Present in up to 20% in infertility patients but in 3% of multiparous women.

6 Unknown Etiology Reflux of menstrual tissue and blood through tubes during menses. Müllerian remnants in the rectovaginal region differentiate into endometrial tissue. Lymphatics may be the conduate shorter menstrual cycles, longer bleeding, and early menarche are risk factors

7 Endometriosis is a common cause of chronic pelvic pain in premenopausal women The most recognized ultrasound appearance of endometriosis is the cyst known as an endometrioma. Traditionally, the sonographic diagnosis of endometriosis was reserved for patients with endometriomas, thus missing the cause of pelvic pain in many patients.

8 Endometrioma of the ovary

9 Get a history during the exam for pelvic pain Acute or chronic Diffuse or focal Cyclical or constant Sharp or dull or cramping? Prior surgery Menopausal and hormonal status Could she be pregnant?

10 During the scan How tender is the patient? Where is the tenderness? Focal? Do organs slide past each other? Push deliberately on each part of the pelvis with the probe and other hand to determine where the pain comes from. Talk to the patient!

11 Adenomyosis: Thought of as endometriosis of the uterus. Characterized by invasion of endometrial glands into the neighboring myometrium. Symptoms: Dysmenorrhea abnormal bleeding, uterine enlargement and tenderness.

12 Adenomyosis: Invasion of endometrial glands into myometrium Ultrasound appearance: Mottled inhomogeneous myometrium globular & asymmetrical uterus, small subendometrial cysts indistinct endometrial stripe.

17 Fuzzy borders of cavity due to adenomyosis

18 Adenomyoma versus fibroid

19 Is this adenomyosis? Ashermans

20 Normal Asherman s

21 Is this adenomyosis? Submucous fibroid

22 Typical endometriomas

23 Typical endometrioma with hydrosalpinx (common)

24 Cystadenoma Endometrioma

25 Ov Cancer Endometrioma

26 Pitfall - struma ovarii Is this endometriosis?

27 Is this endometriosis?

28 Is this a dermoid? Endometrioma mimicking dermoid

29 Three different cases of... Mucinous cystadenoma

30 Is this endometriosis? Hint: Patient is pregnant

32 Decidualized endometrioma

33 Decidualized Endometrioma Cystic masses mimicking an ovarian malignancy during pregnancy, due to areas of nodularity containing blood flow by color Doppler. A prospective diagnosis is possible when a pregnant women has a cyst with solid smoothly lobulated nodules and internal vascularity, stable over several weeks.

35 22 masses in 17 pregnant pts 8 pts went to surgery, 9 (14 masses), had f/u scans and surgery 3-34 weeks later 8 of these masses showed no change and one became smaller. There were no characteristic sono features identified to distinguish decidualized endometriomas from ovarian malignancy. Lesions showing no change over 4 weeks, or lacking solid components and vascularity are more likely to be benign. Groszmann, Howitt, Bromley, Feltmate, Benacerraf, et al. JUM 2014: 33:

36 Several months pp same cyst 22 yo decidualized endo 16 weeks

37 Invasive ovarian cancer at 8 wks

38 Deep implants The pain associated with these implants may be intense but these are small lesiona often not detected by a standard pelvic scan. Some patients with large endometriomas may have few symptoms whereas others with small deep implants have severe dysmenorrhea, dyspareunia and chronic pelvic pain.

39 Unusual appearances of endo implants anywhere Endo implant in CDS Endo in bowel wall

40 Endometriosis of the bladder wall

41 bowel endo

42 Tubal endometriosis

43 Endo implant on appendix Appendicitis!

44 Anterior abdominal wall scar

45 The comet shape

47 Sliding sign Reid et al UOG 2013 Jun;41(6):685-91

49 The comet-sign of endometriosis of the bowel wall

53 Bowel endo vs tumor

54 Colon cancer

55 Crohn s

56 Diverticular abcess

57 Ultrasound for detecting deep endometriosis in recto-sigmoid 19 studies (2669patients) Ultrasound sensitivity and specificity for detecting disease was 91% and 98% respectively. +LR 38.4 and -LR 0.09 Guerriero et al. UOG 2015 Jul 27. doi: /uog.15662

58 Detection of Bowel Endometriosis 10 prospective studies 1106 pts prevalence of bowel endo 24-73% Sensitivity 71-98% (pooled data 91%) Specificity %(pooled data 98%) Accuracy 81-99% +LR LR 0.09 Hudelist et al UOG 2011;37;257

59 Transvaginal scan in deep endometriosis in 10 different pelvic sites 420 pts having ultrasound and laparoscopy (gold standard) for pelvic pain and infertility. Endo focus Sensitivity % Specificity % Bladder Recto-vag.septum Rectal Sigmoid Fratelli et al. UOG 2013;41:69-75

60 Ultrasound vs. MR I98 pts with surgically confirmed endometriosis Abrao et al. found that transvaginal ultrasound had a sensitivity, specificity and accuracy of 98%, 100% and 99% respectively compared to MRI s sensitivity, specificity and accuracy of 83% 98% and 90% for recto-sigmoid endometriosis. Abrao et al. Hum Reprod. 2007;22:3092-7

61 Ultrasound vs. MR for detecting endometriosis The sensitivity and specificity for detecting deep endometriosis by tenderness guided ultrasound was - 86% and 73% respectively while for MRI it was - 90% and 73% respectively. Saba et al. J Magn Reson Imaging :

62 Conclusions Pelvic pain in endometriosis is common and impairs quality of life. Accurate Dx requires an extended ultrasound and history. Patients with endometriosis deserve more than just a series of standard pictures of the uterus and ovaries. Those that we help are among the most grateful of all our patients!

ADENOMYOSIS CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN CHRONIC PELVIC PAIN IN WOMEN ADENOMYOSIS: PATHOLOGY ADENOMYOSIS

ADENOMYOSIS CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN CHRONIC PELVIC PAIN IN WOMEN ADENOMYOSIS: PATHOLOGY ADENOMYOSIS CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN MOSTAFA ATRI, MD Dipl. Epid. UNIVERSITY OF TORONTO Non-menstrual pain of 6 months Prevalence 15%: 18-50 years of age 10-40% of gynecology