The management of adenomyosis depends on the patient’s age and desire for future fertility. Relief of secondary dysmenorrhea caused by adenomyosis can be ensured after hysterectomy, but less invasive approaches can be tried initially. NSAIDs, hormonal contraceptives, and menstrual suppression using oral, intrauterine, or injected progestins or gonadotropin-releasing hormone agonists are all useful. Treatment follows the same protocol as treatment for endometriosis. Uterine artery embolization can be effective (49).
In women with endometriosis, endometrial glands and stroma are found outside the uterine cavity, especially at the cul-de-sac, ovaries, and pelvic visceral and parietal peritoneum. Given that confirmation requires visual diagnosis, the prevalence of endometriosis is unknown. It is thought to occur in approximately 10% of the general female population, 15% to 20% of infertile women, and more than 30% of women with chronic pelvic pain. In some cases, regression can occur spontaneously (50). (See the section below on endometriosis under the heading of chronic pelvic pain and also Chapter 17.)
Patients typically complain of severe dysmenorrhea and cyclic pelvic pain that starts up to 2 weeks prior to menses. The pain can be sharp or pressurelike, localized to the midline or involving the lower abdomen, back, and rectum. Other symptoms include deep thrust dyspareunia, subfertility, irregular bleeding despite ovulatory cycles, and nongynecologic symptoms such as cyclic dyschezia, urinary urgency, frequency, bloating, and rarely hematochezia or hematuria.
Bimanual and rectovaginal examinations may reveal uterosacral nodularity and focal tenderness. Fibrosis resulting from endometriosis can cause a fixed retroverted uterus or laterally deviated cervix or uterus. Bimanual examination can demonstrate a fullness consistent with ovarian cystic endometrioma. Patients can have focal uterosacral or broad ligament area tenderness.
The clinical diagnosis of endometriosis is accurate in approximately 50% of cases. Though a definitive diagnosis of endometriosis cannot be made on image studies, endometriomas are generally distinguishable from hemorrhagic corpus lutea by the appearance on ultrasound. Homogenous hemorrhagic appearing cysts that fail to resolve after one to two menstrual cycles are suspicious for endometriomas. CA125 can be elevated but is a nonspecific and nonsensitive marker for endometriosis. Definitive diagnosis is made by direct operative visualization either laparoscopically or via laparotomy. Active red ﬂame, or colorless vesicles or petechial lesions usually indicate early disease, while powder-burn, fibrotic lesions suggest more longstanding lesions. Suspicious findings should be biopsied for confirmation. Deep infiltrating lesions and peritoneal windows are most often found within the posterior cul-de-sac, especially at the uterosacral ligaments, and may cause pain by penetrating the many nerve endings in this area (51). Patients with endometriosis have nerve fibers in their endometrial tissue, and studies show endometrial biopsy is a potential but as yet unproven diagnostic tool. A double-blind study of 99 women undergoing laparoscopy and endometrial biopsy for evaluation of endometrial nerve fibers found that the biopsy was just as effective as laparoscopy for diagnosing endometriosis (52).
Management of Secondary Dysmenorrhea Due to Endometriosis: Pharmacologic