Endometriosis and adenomyosis

Document Type

Journal Article

Publication Date



Evidence-based Obstetrics and Gynecology




Abortion; Dilatation and evacuation; Medical abortion; Mifepristone misoprostol contraception; Surgical abortion; Vacuum aspiration


© 2019 John Wiley & Sons Ltd. Endometriosis is a common benign gynecologic condition defined as the presence of uterine lining, or endometrium, outside of the uterine cavity. Implants create a proinflammatory environment secondary to the production of cytokines, prostaglandins, and metalloproteinases. The inflammation present in endometriosis lesions leads to scar tissue formation and adhesions between pelvic organs. Severe dysmenorrhea, chronic pelvic pain, and infertility are the most common symptoms of women diagnosed with endometriosis. The presence of endometrial tissue glands and stroma located within the myometrium is termed adenomyosis, or endometriosis in situ. The most common symptoms are menorrhagia and dysmenorrhea. Women with infertility may be at higher risk for adenomyosis. Both endometriosis and adenomyosis can significantly impact work productivity and quality of life. Formal diagnosis for both diseases involves surgery with collection of pathological specimens for confirmation. However, history, physical exam, and imaging can lead to a high clinical suspicion. Endometriosis is distinguished by three distinct manifestations: (i) superficial endometriosis, (ii) ovarian endometriomas, and (iii) deeply infiltrating endometriosis (DIE). Though they can present simultaneously, these three types of endometriosis vary in severity, symptoms, and management. Adenomyosis tends to present with diffuse involvement of the myometrium, but focal lesions called adenomyomas can also occur. Medical therapies for both diseases suppress the endometrial lining and are effective for pain and bleeding symptoms. In the case of endometriosis, conservative surgery may be beneficial for pain relief as well as infertility. However, assisted reproductive technology may be more beneficial for asymptomatic women who have infertility. Conservative surgical therapy for adenomyosis include ablation, myometrial reduction, and uterine artery embolization. Hysterectomy is the definitive therapy for adenomyosis, however remains last resort as many patients desire symptom relieve while preserving fertility. Due to lack of data guiding management, individualized care is often necessary to meet each patient's needs.