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Endometriosis and adenomyosis
Endometriosis is endometrium-like tissue outside the uterus that causes pain and infertility; under the newer guidelines it can be diagnosed and hormonal treatment started on the clinical picture and imaging, without laparoscopy as a precondition.
Why it matters in the exam
The classic exam picture is a young woman with severe period pain that worsens over the years, pain during intercourse (dyspareunia), pain on defaecation during periods and sometimes infertility. Examination may show a fixed, retroverted uterus and tenderness or nodules on the uterosacral ligaments. Ultrasound shows a "chocolate" cyst (endometrioma) with uniform ground-glass echoes. CA-125 may rise, but it is not a diagnostic tool.
Treatment is stepwise: first NSAIDs and hormonal treatment — the combined pill taken continuously, a progestin (dienogest) or a hormonal IUD — and on failure GnRH agonists or antagonists, with protective hormone add-back when they are used for long. Laparoscopic surgery is for failure of medical treatment, a suspected tumour or fertility in certain circumstances; when the main problem is infertility, IVF is usually the effective route. Adenomyosis is endometrial tissue inside the uterine muscle: an older woman, usually after births, with heavy bleeding and pain and a uniformly enlarged, soft uterus; the diagnosis is by MRI or ultrasound, and the definitive treatment is hysterectomy.
Key points
- Symptoms: period pain, dyspareunia, pain on defaecation, infertility.
- Endometrioma: a "chocolate" cyst on ultrasound.
- First line: NSAIDs and hormones; second line: GnRH with add-back.
- Infertility → usually IVF.
- Adenomyosis: large soft uterus, heavy bleeding; hysterectomy is definitive.
Summary table
| Condition | Clinical picture | Diagnosis | Treatment |
|---|---|---|---|
| Endometriosis | Period pain, dyspareunia, pain on defaecation, infertility | Clinical and ultrasound or MRI; laparoscopy if treatment fails or when needed | NSAIDs and hormones (continuous pill, dienogest, hormonal IUD) |
| Endometrioma | "Chocolate" ovarian cyst | Ultrasound: uniform echoes | Surgery by size, symptoms and fertility plans |
| Deep endometriosis | Nodules on the ligaments, pain on defaecation or urination | MRI or expert ultrasound | Surgery in an experienced centre |
| Resistant disease | No response to first line | — | GnRH agonist or antagonist with add-back |
| Infertility with endometriosis | Difficulty conceiving | — | IVF; surgery in selected cases |
| Adenomyosis | Older, after births; heavy bleeding and pain; large soft uterus | MRI or ultrasound | Hormones (hormonal IUD); hysterectomy — definitive treatment |
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Sources
- ESHRE Guideline: Endometriosis, 2022 — Diagnosis and treatment of endometriosis
- ACOG Practice Bulletin No. 114, 2010, reaffirmed — Management of Endometriosis
- NICE guideline NG73, 2017, updated 2024 — Endometriosis: diagnosis and management
- Berek and Novak's Gynecology, 16th edition (2019) — Endometriosis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.