CASE 8: DYSMENORRHEA & ENDOMETRIOSIS
DYSMENORRHEA
 Crampy hypogastric pain
 Occurs before, during and immediately after menses
 Accompanying symptoms: Nausea, Vomiting, Headache
CLASSIFICATION:
PRIMARY DYSMENORRHEA
 Set in at the time related to menarche (post-menarcheal)
After menarche, the menstrual cycles are anovulatory hence NO
dysmenorrhea. During anovulatory cycles chances are menstrual cycles
are without phase because there is a lot more PG from the
endometrium in a woman with a secretory endometrium. That is the
reason why when a patient have menarche at 12, most likely at 14, 15
or 16 that will be the time they will experience dysmenorrhea. This is
the age where cycles start to be ovulatory where time has passed for
the maturity of HPO axis.
 Pathology: ↑ PGF2α
 Pelvic examination: Normal (Cannot demonstrate an
organic or anatomic pathology to explain the pain)
 Treatment:
Medication:
 Standard: NSAIDS (PG Synthetase Inhibitor)
o Mefenamic acid (Lesser SE: GI upset)
o Ibuprofen, Naproxen (Flanax), Indomethacin
Diet:
 Just before period, a woman is heavier because of
nd
the retention of water in the 2 half of the cycle
 Green mango + salt/ bagoong – adds to the
premenstrual retention of water
SECONDARY DYSMENORRHEA
 Set in after age 20 (several years, after 20 years)
 Pathology: Positive anatomic problems
CAUSES:
1. Endometriosis
2. Adenomyosis
 Old Term: Endometriosis Interna
 Still WITHIN the confines of the myometrium
 At the time of menstruation, there is bleeding within
the fibers of myometrium giving rise to pain
3. PID
4. Pelvic Congestion Syndrome
5. Anything within the endometrial cavity
o Submucous myoma
o IUD
TX: Geared towards organic/anatomic causes
ENDOMETRIOSIS
 Presence of the endometrial glands or stroma outside the
confines of the endometrium
 Anything outside the confines of the uterus
Pathogenesis:
In the histology of the uterus, it is made up of
endometrium, myometrium & serosa. The endometrium is
made up of 3 layers: Compacta, Spongiosa & the Basalis (C & S
- Functional layer, B – Regeneration)
During menses, the glands and stroma that are in the
functional layer dislodge (sloughed off). If the glands & stroma
are supposed to be coming out as menstrual discharge BUT
reflux back to the tube, then this is the MOST COMMON
pathogenesis of endometriosis.
Theory/ Causes of Endometriosis:
1. Sampson’s Theory of Transtubal Reflux/ Regurgitation
 Retrogade menstruation/ Accumulation of Menstrual
Blood due to Outflow Obstruction:
 Most common theory because a lot of the endometriosis’
sites can be explained by this theory & the most frequent
sites are the ovaries, cul de sac, rectosigmoid & the
peritoneum .
Causes:
 Review Case 3, Amenorrhea & Congenital Anomalies:
Imperforate Hymen & Complete Transverse Vaginal
Septum
 Cervical Stenosis (may be Acquired) from those who
had previous procedure or operation done on the
cervix
The most common site of endometriosis is the ovaries. As
the menses will come out from the tube they will just implant
on the ovaries. Usually it is in this area of the pelvis that will
have a lot of endometriosis.
Remember the abdominal wall: skin, subcutaneous, fascia,
muscle, & peritoneum. There can be peritoneal endometriosis
& this will not be explained by Trans tubal theory. In the Trans-
tubal regurgitation, it will dislodge in the most dependent area
of the pelvis:
In the area of the cul de sac that goes from the posterior
peritoneum of the vagina (cul de sac is between the posterior
surface of the uterus & the rectosigmoid or at the area of the
uterosacral ligaments)
2. Vascular / Lymphatic Dissemination
 Anything that is FAR from the pelvis can be explained by
this
During menses, the blood vessels in the endometrium, the
spiral arterioles are open so endometrial glands may only go
into the myometrium & the vascular supply of the uterine
vessels, dislodged endometrium may only go to the blood
vessel or the lymphatic.
3. Coelomic Metaplasia
 Peritoneal endometriosis
 Tissues of the peritoneum develop into endometrial like
tissue
Both theories: Vascular & Coelomic Metaplasia may explain
endometriosis in other areas of the body.
 Epistaxis – Endometrial glands in the nasal mucosa. A
woman who nose bleeds every during menses
TX: Destroy the endometrial implants of the nasal mucosa
(Localized focal depending on how much epistaxis)
 Hemoptysis – Endometriosis of the Pleura
4. Immunologic Theory of endometriosis
 Newest theory
 Those who developed endometriosis have something that
nourishes the endometrial glands & stroma to grow.
 Present certain substances: interleukins, cytokines
No one of these theories will explain it solely. If laparoscopy is
done, scoped at the time of menstruation, all will have blood in
the pelvic cavity. So all will have reflux of menses into the
tubes & into the pelvic cavity but NOT all will develop
menstruation so Trantubal Theory will go hand in hand with
what we term as Immunologic Theory of endometriosis. For
those with endometriosis, there is something more than
Transtubal regurgitation.
5. Genetics – Family History
6. Direct implantation
 Iatrogenic
 Endometriosis of episiotomy wound, incision in the
abdomen for CS
 Symptoms: Lump on episiotomy during menses &
disappears when there is no menstruation.
 For patients who had undergone episiotomy with
episiorrhapy:
After delivery of the placenta, the decidua (remember
endometrium) some will come out & during episiotomy, if
some of the decidual cells are caught during episiotomy then
this decidua will becomes endometrial glands & stroma
Clinical Diagnosis of Endometriosis:
1. Secondary Dysmenorrhea
2. Acquired & Progressive Pain + Bowel Symptoms
 Usually GIT symptoms are prominent with Endometriosis
 The most dependent area: endometrial implants on the
serosa of recto-sigmoid that bleeds every menstruation
causing colon to do peristalsis. At the time of
menstruation there is rectal discomfort (pain) or at the
time menstruating there is a need to go to the rest room
because there is feeling to move the bowels.
 Pain that lets the patient stay home from work & class
3. Dyspareunia, particularly on deep penetration
 Sometimes endometriosis would be felt at the utero-
sacral ligaments
4. Infertility problem
Pelvic examination:
1. Retroverted uterus
 Normal position: Anteversoflexed
 Retroverted: directed towards the back because it is being
held up by the endometrial implants or adhesions at the
posterior portion of the uterus
 Because there are adhesions between the rectosigmoid
(RS) and the uterus. It keeps the uterus close to the RS.
2. Uterosacral nodularities
 To elicit tenderness, it is ideal to check at the time of
menstruation because that will be the time it will be very
tender
3. Enlarged ovaries
 May or may not have
 May feel an adnexal mass, an enlarged cystic ovaries
Definitive Diagnostic Procedure:
1. UTZ (+) ENDOMETRIAL CYSTS OF THE OVARIES
 Can be pelvic, trans-vaginal or trans-rectal dependent on
the intactness of the hymen
 Medium to low level echoes within the mass
corresponding to the old menstrual blood
In endometriosis, because of the presence of endometrial
glands & stroma, when the woman menstruates, blood will
accumulate to the ovaries. Over so many years, blood
accumulated in the ovaries would make it grow bigger.
Hopefully before the endometrial cyst will rupture, she would
seek consult & usually this is one cyst that would let the
sonologist think of endometrial cyst
Sonologist will detect an adnexal mass but will not tell the type
of ovarian cyst but in endometrial cyst because of the presence
of medium to low level echoes they can come up with the
diagnosis of Endometrial cyst of Ovaries
HOWEVER IF it does not involve the ovaries, you will not see
anything
2. Laparoscopy: (+) ENDOMETRIOSIS
 A minimally invasive procedure to visualize the abdominal
cavity
 An endoscopic procedure
 GOLD STANDARD: PID & ENDOMETRIOSIS
 For diagnosis if there is no result from the UTZ
 For therapy, if there is (+) Endometrial Cyst from UTZ
What can you see in laparoscopy?
 See external architecture of pelvic organs (outside)
 Endometrium cannot be seen by laparoscopy which is
inside the endometrial cavity but with hysteroscopy
 Elevate the uterus to be able to see the back which are
the: (+) Nodularities of uterosacral ligaments, Implants of
endometriosis on the surface of the uterus or ovaries or
fallopian tubes
 Via laparoscopy, there is a need to know the different
picture of the endometrial glands:
It can be a vesicular type of endometriosis, chicken pox-like on
the surface of the ovary. These would mean the beginning of
the endometrial implant becoming red, yellow then bluish
black color (cigarette burns).
You can see the endometrial implants on the surface of the
pelvic organs, peritoneal surface of the abdominal cavity.
Once diagnosis has been made, we can go to therapeutic
operative laparoscopy. By principle, destroy/ eradicate of the
endometrial implants via excise, cauterize or laser. But with
this the patient can always have a recurrence.
NOT CA 125:
 NOT SPECIFIC
 ↑: Pregnancy, PID, Myomas, Ovarian CA & Endometriosis
Treatment
Definitive Treatment: Bilateral Oophorectomy
 Get rid of the culprit, ovaries. If the ovaries are no longer
present then there would be no menses & no longer make
Estrogen which responsible for the stimulation of
endometrial implants
 Many times, it cannot be done on patient in 20s to 30s,
making her menopausic because endometriosis usually
affects young patients.
Alternative treatment:
Medical:
 Objective: to make her AMENORRHEIC
 Principles: make her PSEUDO-MENOPAUSIC OR PSEUDO-
PREGNANT because in both conditions, pregnancy &
menopause are situation where you have physiologic
amenorrhea.
Pseudo-pregnancy:
 Continuous OCP
 Continuous Progesterone because in the pregnant the
most predominant is progesterone
 But OCP for contraception - Take it for 21 days
Pseudo-menopausic
 Danazol
Worst SE: Masculinizing effect of the drug
 GnRH Agonist
SE: symptoms of menopause
Read about “add-back therapy” which means you are
giving small doses of hormones to offset the symptoms of
menopause
Surgery
Radical
 Take out everything uterus: TAHBSO for endometriosis
 Do not mistake this as radical surgery for cancer
Conservative
 Oophorocystectomy - take out endometrial cyst of the
ovary
 Salphingooophorectomy - adnexa
 Also excision cautery of all the endometrial implants
As long as there is menstruation, there is recurrence because
definitive treatment is to GET RID OF THE OVARIES.
Incidence: ↑ because women try to postpone pregnancy, more
focus in the career.
Remember:
 The extent of the symptoms do not always parallel the
extent of disease
 Endometriosis is an ENIGMATIC disease
E.g.
 A young girl 21 years feels comfortable except for the
slight dysmenorrhea, she comes becomes she’s bothered
by it & she never had it before. You do pelvic examination
it is Stage 4 Endometriosis
 22, F not in school because she’s practically in pain, you
do pelvic examination & its normal.

CASE 8
32 year old G2P1 (1011) complains of hypogastric pain during menses. She has been experiencing this pain for the past 3
menses. There was also increase in amount of menses. She used to consume: 1 – 2 pads/day but for the past 3 months, she
rd nd
consumed 2 – 3 pads/day. LMP: May 3 wk, 2013. PMP: April 2 wk, 2013 PPE: BMI 22; pink palpebral conjuctival abdomen:
flabby soft non-tender, no palpable mass; Speculum: cervix, pink smooth; IE: cervix – firm, long, closed; uterus – symmetrically
enlarged to 3 mos., retroverted; adnexa – no palpable mass nor tenderness.

DX: ADENOMYOSIS

Basis:
 Dysmenorrhea x 3 months: Secondary dysmenorrhea
 HMB x 3 months
 Symmetrically enlarged x 3 months
 32 Gravida 2

Symmetric: Adenomyosis or Pregnancy

Asymmetric Nodular Enlargement: Myoma

Difference is the consistency of the uterus

 Pregnant: soft symmetrical enlargement
 Adenomyosis: Firm, symmetrical enlargement

Remember:
Endometriosis Adenomyosis
Nulligravid Nulligravid Multiparous?
Younger Older

DX: Confirmed bu UTZ

TX:
 do HYSTERECTOMY (DEFINITIVE TREATMENT to remove
the uterus to get rid of the pain & other problems)

BUT IF want to have another child:

 Initially just treat the symptoms
 Give NSAIDS:
o Causes myometrial relaxation
o Decreases the menstrual blood flow

Conservative Surgical objective of Endometriosis:

 Try to restore the normal anatomy of the pelvis
 Try to restore also the fertility of the patient