there is a lot of discussion on managing adenomyosis on face book, here is my presentation..................

1. MANAGING ADENOMYOSIS ?
a dilema…………….
narendra malhotra
jaideep malhotra
neharika malhotra
www.malhotrahospitals.com
AGRA

2. • AFFECTS ONE IN ALMOST 15 WOMEN
• REPRODUCTIVE AGE GROUP
• CAUSE NOT YET KNOWN
• NOT CLEAR HOW IT CAN BE PREVENTED
• NOT KNOWN HOW TO PREDICT THE
DEVELOPMENT OF THIS DISEASE
• NO SIMPLE TEST EXCEPT ON SURGERY
• EVEN ON OPERATION THE DIAGNOSIS IS MOSTLY
AN EDUCATED GUESS
• THERE ARE ATLEAST 4 TREATMENT OPTIONS
• NONE BETTER

3. WELCOME TO THE WORLD OF
ECTOPIC
ENDOMETRIUM:ADENOMYOSIS
20%
25%
15%
25%

4. What is Adenomyosis?
The penetration and growth of endometrial tissue from
the uterine lining into the myometrium (uterine muscle) is
called adenomyosis or internal endometriosis. This
disease may coexist with external endometriosis in which
endometrial implants are located outside the uterus. The
abnormally located endometrial tissue, like the normal
endometrium, tends to bleed with the menses. The blood
and debris may accumulate in these misplaced glands
creating small fluid collections inside the uterine wall. This
penetrating and functioning endometrial tissue may lead
to swelling; the uterus may become larger and globular.
Adenomyosis may present as a diffuse condition or it may
be focal. In the latter, there are local areas of swelling, so-
called adenomyomas, that may mimic other uterine
masses.

6. Definition
adenomyoma describes a focus of
adenomyosis within a leiomyoma
(fibroid). Both conditions are
common so it is not surprising that
this overlap condition may occur.

7. Definition
The gland tissue grows
during the menstrual cycle
and then at menses tries to
slough, the old tissue and
blood cannot escape
This trapping of the blood and
tissue causes uterine pain in
the form of monthly menstrual
cramps.
It also produces abnormal
uterine bleeding.

8. The typical symptoms include
• Pelvic pain,
• Dysmenorrhea,
• And menorrhagia unresponsive to hormonal therapy or uterine
curettage.
• Subfertility.And pregnancy termination.
classic presentation
Cyclic, cramping uterine pain beginning later in reproductive life
(generally after age 35) and often associated with prolonged and
heavy menses

9. Pelvic pain
In studies of chronic pelvic pain in which
women had hysterectomies, the
incidence of adenomyosis is about 15%
to 25%

10. 111 specimens of uteri and cervices
17 with 19 with 39 with 36 with
adenomyosis adenomyosis with leiomyomas neither.
alone leiomyomas alone
from patient records the pregnancy terminations rate was:
58.8% 47.4% 20.5% 22.2%
Levgur M, Abadi MA, Tucker A.2000 May

11. ADENOMYOSIS vs FIBROIDS
• Most commonly adenomyosis is mistaken for another common
condition, uterine fibroids. There is however a fundamental
difference between a fibroid (a distinct tumor) and adenomyoma.
Each fibroid originates from one abnormal cell. Under the effect
of estrogen this cell multiplies. The growing tumor may displace
and compress tissues but it does not invade the surrounding
uterine muscle. Because of this growth pattern of fibroids, it is
possible to remove all of the tumor without removing any normal
uterine tissue during myomectomy (surgical removal of fibroids).
In contrast, adenomyoma is not a discrete tumor but rather a local
swelling of the uterine wall as a result of the penetration of
endometrial tissue. Therefore it is not possible to remove tissue
affected by adenomyosis without actually removing the involved
uterine muscle.

12. Definition
Adenomyosis is a
benign disease of the
uterus characterized by
ectopic endometrial
glands and stroma
within the myometrium
It is associated with
myometrial hypertrophy
and may be either
diffuse or focal.

13. Diagnosis
(Discepoli S, Leocata P, Giangregorio F).examined 1500 surgical bits
had been histologically examined.. In all they have found 310 cases of
adenomyosis (20,6%);
The diagnosis can only be proven by the
pathologists
A good gynecologist may suspect adenomyosis
based on the clinical factors, but the final diagnosis
usually has to wait until hysterectomy is performed

14. Pelvic exam
there may be uterine enlargement
from about 6-10 weeks pregnancy
size
The uterus can feel soft and boggy
on pelvic exam. Sometimes
adenomyosis is associated with
uterine fibroids (leiomyomata)
repeated bimanual
examinations, over several
months, just before and after
menstruation have been
recommended to detect fluctuating
changes in contour, size and
consistency of the uterus

15. Sono-Hysterography
the presence of ill defined
areas of contrast
intravasation extending
perpendicularly from the
uterine cavity into the
myometrium isThe most
characteristic feature of
adenomyosis on
hysterography.
Unfortunately, the sensitivity
of this technique is too low
for clinical practice.

16. Hysterography
Filling of cavities in the uterine wall
during hysterography was
observed in 54 of 320 surgically
excised specimens in which
metal threads had been inserted
at different levels for
identification.
Adenomyosis may have accounted
for these cavities in 24%.
True adenomyomas (encapsulated)
are uncommon tumors of the
uterus. At
hysterosalpingography, detection of Radiological Society
a network of fine channels in a very of North America ,
well-circumscribed area of the
Radiology, Vol
myometrium, connected with the
118, 581-586,1976
uterine cavity, allows a preoperative
diagnosis

17. Myometrial biopsy laparoscopically
or sonographically guided

18. Myometrial biopsy laparoscopically or
sonographically guided
a larger study by Popp et al. who took not only
needle biopsies immediately after
hysterectomy but also at the time of
laparoscopy as well as transvaginally under
ultrasound guidance A single myometrial
biopsy picked up only 8% to 19% of women
with adenomyosis. The sensitivity of random
needle biopsy is therefore too low for clinical
practice.
**Popp LW, Schwiedessen JP, Gaetje R. Myometrial biopsy in the
diagnosis of adenomyosis uteri. Am J Obstet Gynecol 1993;

19. CA 125

20. CA 125
adenomyosis is associated with increased
numbers of myometrial macrophages,
elevated antiphospolipid auto-antibodies
and CA 125 levels in peripheral blood.
Ota H, Maki M, Shidara Y, Kodoma H, Takahashi H, Hayakawa M et al..
Effects of danazol at the immunologic level in patients with
adenomoysis, with special reference to autoanyibodies: multicenter
cooperative study. Am J Obstet Gynecol 1992; 167:481-6.

21. TVUS
The technique is strongly operator
dependent

22. Transvaginal criteria
(used separately or in combination)
• • Uterine enlargement in the absence of leiomyomas
• • Asymmetric enlargement of the anterior or
posterior
• myometrial wall
• • Lack of contour abnormality or mass effects
• • Heterogeneous, poorly circumscribed areas within
the
• myometrium
• • Hyperechoic islands or nodules, finger-like
projections or
• linear striations, indistinct endometrial stripe
• • Anechoic lacunae or cysts of varying size
• Color flow low velocity low reisitance within the
lesion

23. normal myometrium NORMAL
(M), homogeneous
echotexture
The subendometrial haloas a
thin hypoechoic band
(arrows).
The endometrium is
uniformly echogenic

24. E = endometrium
Adenomyosis
myometrium is thickened ventrally
and has a heterogeneous echotexture
The echogenicity of the ventral myometrium is
decreased relative to that of the dorsal
myometrium
myometrial cyst (curved arrow).
excentric endometrial cavity
decreased uterine echogenicity without lobulations, contour
abnormality, or mass effects,

25. MRI

26. MRI CRITERIA
• Focal or diffuse thickening of the junctional zone
• • Low signal intensity uterine mass with ill-defined border
• • Junctional zone thickness 12mm
• • Poor definition of junctional zone border
• • Localised high signal foci within an area of low signal
• intensity
• • Linear striations of increased signal radiating out from the
• endometrium into the myometrium
• • Bright foci in endometrium of similar intensity to the
• myometrium (T1-weighted)
• • Ratio of maximal junctional zone thickness to myometrium
• thickness (ratiomax)

27. MRI
Magnetic resonance imaging was
superior to TVS for the diagnosis
of adenomyosis.
Magnetic resonance imaging had a
higher specificity than TVS, but
their sensitivities were in line.

28. MRI
On T2-weighted MRI, focal
adenomyosis are seen
in areas of abnormal low
signal intensity within the
myometrium in
approximately 50% of
patients. These foci
correspond to islands of
heterotopic endometrial
tissue, cystic dilatation of
heterotopic glands, or
hemorrhagic foci.

29. MRI
On T2-weighted MRI, diffuse
adenomyosis usually
manifested as diffuse
thickening of the junctional
zone with homogeneous low
signal intensity .T2-weighted
imaging provided significantly
better lesion detection than
unenhanced or contrast
material–enhanced T1-
weighted imaging

30. A challenge……….
• Adenomyosis poses a significant
challenge in the management of
infertile women
• Hysterectomy is the only definitive
treatment for women with adenomyosis
but this is not an option for women who
are infertile and keen to conserve the
uterus

31. MANAGEMENT
10 different options

32. Treatment
• Advances in treatment have been limited by the
difficulties in determining a clinical diagnosis
and the lack of a specific intervention
• Different surgical and medical modalities of
treatment have been addressed in the literature
but many of these have not been tested
specifically for adenomyosis uteri.
• In the absence of treatments directed at the
disease itself, management is often directed at
the symptoms.

33. MANAGEMENT AIMED AT GOALS
• PAIN AND MENORRHAGIA
• FERTILITY PRESERVING
• SYMPTOMATIC MEDICAL
• CONSERVATIVE SURGERY
• RADICAL SURGERY
• OTHERS(LNG-
IUS, OCPS,RU486,DANAZOL,PROGESTERONES
, GNRh ANALOGUES,HFUA

34. Medical Approaches
• As previously stated, a PROGESTERONES
constant feature of medical CONTINOUS OCP
therapy for adenomyosis is DANAZOL
that, over the years, it has NSAID’S
mimicked that which has been GnRh Analouges
applied to endometriosis. At RU 486(MIFIPRISTONE)
present, medical therapy of LNG-IUS
adenomyosis can be attempted HIGH FREQ ULTRASOUND
for symptomatic
relief, especially in
premenopausal women and in
women who wish to become
pregnant

35. SURGICAL
• LAPAROSCOPIC MYOMETRIAL
ELECTROCOAGULATION
• LOCALISED EXCISION
• UAE(UT A EMBOLISATION)
• LAPAROSCOPIC UT A LIGATION
• ENDOMETRIAL ABLATION
• HYSTRECTOMY

36. MANAGEMENT
The only definitive treatment for
adenomyosis is total
hysterectomy, with or without ovarian
conservation.

37. Is There Medical Treatment for
Symptomatic Adenomyosis?
• Frequently the moderately enlarged uterus is asymptomatic and no treatment is necessary.
Temporary relief of very painful heavy periods can be achieved with GnRH agonists .
• These medications cause a menopause-like state with complete cessation of ovarian
function and menses, causing the abnormal tissue to shrink.
• This temporary reversible state permits an anemic patient to restore a normal blood
count, especially when iron supplements are prescribed.
• However, GnRH agonists are not easy to tolerate, causing menopausal symptoms such as
hot flashes.
• Other consequences include weakening of the bones, alteration of the cholesterol profile
(decrease in "good" cholesterol, HDL, and increase in "bad" cholesterol, LDL)
• For these reasons, this type of medical treatment is usually limited to six months. Upon
cessation of GnRH treatment, the painful heavy periods tend to resume.
• GnRH agonists are also used to treat infertility associated with adenomyosis. There are a
few anecdotal reports of successful pregnancies after a six to eight month course of GnRH
agonists.
• One should be aware that such treatment may be successful in mild cases of adenomyosis
but may fail in more severe cases.
• Progesterone is usually ineffective in the treatment of adenomyosis or, at best, is only
temporarily and partially helpful.
• Similarly, birth control pills are ineffective or only temporarily and partially helpful.
• Levonorgestrel containing IUD helps relieve pain and heavy bleeding but only temporarily.

38. PAIN MANAGEMENT
• (NSAID’s, or hormonal suppression with
progesterone or GnRH agonists). Newer
medical therapies such as mifepristone and
the levorgestrel intrauterine system have
been described but these are not compatible
with ongoing fertility therapy.

39. Severe Pain and Heavy Menstrual
Bleeding Due to Adenomyosis
• B.B., a 40 year -old woman, was seen because of a history of ten years of severe
menstrual pain and excessive bleeding lasting ten days of each month. She was
obviously anemic. She had consulted many physicians, had several ultrasound
studies and a laparoscopy. She was told that she had multiple fibroids and that a
myomectomy was impossible; recently a physician had told her that any such
attempt would be "a bloody mess" and inevitably result in hysterectomy.
• On examination, her uterus was enlarged to the size of a 16 week pregnancy with
a prominent swelling involving the upper uterus. On high resolution transvaginal
ultrasound a nine centimeter "tumor" was identified, but its boundaries were ill-
defined; the appearance suggested an adenomyoma more than a fibroid. The
patient was told that if it was a fibroid it would be removed with an excellent
chance that she would be able to conceive in the future. However, she was
informed, if in fact surgery revealed an adenomyoma, resection would solve her
medical problem but her uterus would be missing significant portion of its
muscular wall, precluding future pregnancy. At surgery she was found to have
adenomyosis, confirmed during surgery by a frozen section pathology evaluation.
Therefore, an adenomyomectomy was performed with reconstruction of the
remaining uterus. Blood loss was minimal and the postoperative recovery was
smooth. One year later she reported that she has very light regular periods
lasting three days. She has no pelvic pain.

40. Treating Adenomyosis with the
Progesterone IUD LNG-IUS
• Adenomyosis has been a frustrating disease to treat; medical
treatment with oral progesterone or birth control pills often does
not work and uterine artery embolization often fails. Hysterectomy
is the only treatment known to be highly (100%) effective.
• According to a recent study, the progesterone-containing IUD
(Mirena) can help with menstrual cramping in about 70% of
women.
• The IUD probably works because it slowly gives off progesterone
directly to the lining cells in the uterus and in the uterine muscle
wall. Progesterone causes the cells to shrink and produce less
prostaglandin, the protein that causes cramping.
• The most common side effects from the IUD were weight gain
(29%), benign ovarian cysts (22%) and lower abdominal pain
(12%).If you have pain from adenomyosis, this IUD is probably
worth considering.

41. Levonorgestrel-releasing
intrauterine system
In 1997, Fedele et al. utilized the
levonorgestrel-releasing intrauterine
system (LNG-IUS) for relief from
adenomyosis-associated menorrhagia.In
23 women with recurrent menorrhagia
and adenomyosis diagnosed with
TVS, the insertion of the system induced
amenorrhea in two, oligomenorrhea in
three, spotting in two and regular flows
in the remaining 16 women after 1 year.
Significant increases in
hemoglobin, hematocrit and serum
ferritin were also observed. This small
trial documented that the LNG-IUS
produces the same positive effects on
excessive bleeding also when
adenomyosis is present.

42. Gonadotropin-releasing Hormone
Analogues

43. • In 2002, Imaoka et al. investigated a possible role of
gonadotropin-releasing hormone analogues for the
treatment of diffuse adenomyosis, as evidenced by
MRI. They administered the analogue over a 6-month
period to 31 patients with MRI features suggestive of
diffuse adenomyosis and concluded that use of
gonadotropin-releasing hormone analogues is
associated with a decrease in myometrium JZ width.
Furthermore, asymmetric adenomyosis with high-
signal intensity foci appears to be the most sensitive
to hormonal therapy

44. • The medications GNRH agonists can cause cessation of the
periods and associated menstrual cramping and even lead to
shrinkage of the swelling associated with adenomyosis.
• However, the effect is temporary-when the medication is
discontinued, the symptoms return.
• At the present time, the only treatment for adenomyosis is
surgery.
• In situations where the adenomyosis is confined to isolated
areas in the muscle wall, an attempt may be made to
surgically remove these areas and repair the rest of the
uterus.
• In situations where the majority of the uterus is
affected, hysterectomy may be the only cure.

45. Fertility enhancement
• As such, there are no specific procedures to enhance
fertility specifically directed towards adenomyosis.
• The therapeutic pathway for fertility management is
not heavily influenced by the presence of
adenomyosis.
• Treatment protocols may need minor alterations.
• If a woman requires assisted reproduction, one might
consider downregulation with a GnRH agonist and
using a long protocol (as opposed to daily GnRH
agonist doses or antagonist protocols) to suppress
disease activity before stimulation is begun.

46. Gonadotropin releasing hormone agonists in the
treatment of adenomyosis with infertility
(1) GnRH- agonists is efficient in reducing the
adenomyotic uterine size, and may facilitate
fertility.
(2) For ademyomata associated with
infertility, GnRH-alpha therapy may avoid the
risk of rupture of uterus which may occur after
adenomyomectomy pregnancy.
(3) For infertility, GnRH-alpha treatment before
laparoscopic surgery greatly decreases surgical
difficulties and blood loss in certain cases.
Obstetricts and Gynecology Hospital, Shanghai Medical University, Shanghai
200011
Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6

47. Can Uterine Artery Embolization Be
Used to Treat Adenomyosis?
• Only a small number of women with
adenomyosis have been treated with uterine
artery embolization (UAE),
• and the results so far have been
disappointing.
• Symptoms appear to improve for a year or
two, but most women then have recurrence
of symptoms.

48. Uterine arterial embolization in the
treatment of adenomyosis
UAE is an
effective and
safe method in
the treatment of
adenomyosis.
BUT the
recurrence rate
is not yet
evaluated.

49. Uterine arterial embolization in the
treatment of adenomyosis
UAE procedures were performed in 23 patients with
adenomyosis. After treatment the symptoms and uterine
volume of all patients were investigated.
All clinical symptoms of 23 patients relieved.
•Dysmenorrhea completely disappeared in 19 patients, significantly alleviated
in 2 patients. But in other 2 recurred.
•The uterine volume shrunk significantly [(50 +/- 18)%] vs [(100 +/- 0)%].
•The blood flow within the uterine and lesions detect by color doppler flow
imaging decreased immediately after UAE.
•Low-abdominal pain and slight fever were seen after treatment and
recovered within 1 - 2 weeks.
Chen C, Liu P, Lu J, Yu L, Ma B, Wang J, Liu P
Zhonghua Fu Chan Ke Za Zhi 2002 Feb; 37:77-9

50. Uterine Artery Embolization
• In 2001, Siskin et al. retrospectively evaluated the MRI
appearance and clinical response of patients undergoing
uterine artery embolization (UAE) for the treatment of
menorrhagia due to adenomyosis. Of the 15 patients in
the study, five had diffuse adenomyosis without evidence
of uterine fibroids, one had focal adenomyosis without
evidence of uterine fibroids and the remaining nine had
adenomyosis with one or more fibroids. At 12 months
follow-up, 92.3% patients reported significant
improvement in symptomatology and quality of life.
Postoperative MRI revealed significant reductions in
median uterine and fibroid volume and mean JZ.
Larger, prospective studies are needed to establish the
safety and efficacy of this procedure in women with
adenomyosis.

51. • Several reports followed, mostly from the Far
East, which confirmed that UAE is an
effective therapy for adenomyosis.
• Worth mentioning is a South Korean study
that investigated UAE in women with
adenomyosis, but no fibroids.Several reports
followed, mostly from the Far East, which
confirmed that UAE is an effective therapy for
adenomyosis.

52. Surgical Approaches
• In a recent paper, Rabinovici and Stewart reviewed
new interventional techniques that have been
introduced over the last few years in order to find an
adequate noninvasive therapy for adenomyosis.
• They warn that there are no evidence-based data to
guide us in using minimally invasive therapy, since
most data regarding these evolving therapies come
from the inadvertent treatment of adenomyosis in
studies designed to treat uterine leiomyomata.
• For this reason, all data are from case reports or small
case series.
• An additional problem is represented by the lack of
an agreed imaging definition of adenomyosis, and so
therapies that do not excise the uterus have no 'gold
standard' for comparison.

53. • New surgical procedures such as laparoscopic uterine
artery ligation,
• laparoscopic myometrial electrocoagulation,
• high intensity focused ultrasound
• and uterine artery embolization have all been
proposed as therapies for adenomyosis.
• These procedures are largely in the experimental
phases.
• Their impact on future fertility and the uterine
integrity in case of electrocoagulation remains
uncertain.
• As such, they should not be considered as therapeutic
approaches for women seeking fertility.

54. conservative surgery for adenomyosis
The conservative surgery for
adenomyoma can reduce symptom and
raise pregnancy rate significantly, it can
be accepted by young women who
want to preserve their reproductive
capacity.
Though the pregnancy rate of
conservative surgery for diffused
adenomyosis was low, it still has
therapeutic value
Zhongguo Yi Xue Ke Xue Yuan Xue Bao 1998 Dec; 20:440-4

55. Surgical resection

56. Surgical resection with GnRh tt
• Microsurgical complete resection of the visible
adenomyotic area followed by treatment of
GnRH agonists has been described.
• This surgical approach is also called an
adenomyomecotmy.
• Live births have resulted after it.
• The rationale for medical adjuvant therapy is the
assumption that surgical resection of the
pathological area without damage to the uterine
cavity is incomplete

57. Endometrial ablation for menorrhagia
Endometrial ablation is unlikely to help
women with symptomatic adenomyosis. This
is simply because the destruction of the
endometrium does not elminate the
adenomyosis, which is located much deeper
in the uterine wall. Uterine artery
embolization in most cases also fails to
resolve the symptoms of adenomyosis.

58. What is the Surgical Treatment for
Adenomyosis?
Hysterectomy is currently considered by most the
only effective treatment for symptomatic
adenomyosis.
In recent years I have successfully treated many patients
with adenomyosis by surgically removing only specific
areas of the uterus containing the bulk of the disease
(as carefully defined by transvaginal ultrasound). In
addition, I have found it helpful to surgically remove
the lining of the upper portion of the uterine
cavity, since this is the source for regrowth of
adenomyosis and this, in effect, prevents recurrence
of adenomyosis. This is followed by reconstruction of
the uterus, resulting in a near normal sized uterus.
This results in resolution of the pain and normal to
very light periods. The drawback of this surgical
treatment is that pregnancy is no longer an option

59. Dilema & frustration remains …..
What Is the Treatment for
Adenomyosis except Hystrectomy….

60. MRI-guided Focused Ultrasound
Surgery

61. MRIgFUS represents a new, safe
and effective method for the
ablation of adenomyotic tissue

62. MRIgFUS
• significant improvements in dysmenorrhea and
menorrhagia with a decrease in uterine size in
most patients. In addition, MRI evaluation
produced results suggestive of coagulation
necrosis of adenomyosis in the majority of
patients.
• some reports suggest that there may be efficacy
in techniques such as uterine artery
embolization and MRI-guided focused
ultrasound surgery (MRIgFUS).

63. MRIgFUS
• Recently, Fukunishi et al. evaluated the thermal
ablative effects of MRIgFUS on adenomyosis in
improving clinical parameters in 20 premenopausal
women; since adenomyosis symptoms are similar to
those of uterine myomata, they used the symptom
severity score questionnaire available for evaluating
the effect of MRIgFUS on myoma.
• They reported that most adenomyotic lesions could
be satisfactorily ablated close to the serosal surface or
the endometrium and, at 6 months, the mean uterine
volume had decreased by 12.7%. Symptom severity
score improved significantly during the 6 months of
follow-up and no serious complications were
observed.

64. Two other novel approaches

65. Inhibitors of Angiogenesis
New knowledge of a modified angiogenesis in
heterotopic uterine mucosa in case of endometriosis
and adenomyosis is opening the way for a new
treatment line. Starting from the observation that
dopamine and its agonists, such as cabergoline
(Cb2), promote endocytosis of VEGF receptor
(VEGFR)-2 in endothelial cells, thereby preventing
VEGF–VEGFR-2 binding and reducing
neoangiogenesis, the group of Pellicer et al. has now
evaluated in an animal model the antiangiogenic
properties of Cb2 on the growth of established
endometriosis lesions. After treatment with Cb2, they
found a significant decrease in the percentage of
active endometriotic lesions and of cellular
proliferation index, associated to a reduced
neoangiogenesis, and a significant modification of
gene expression

66. • In women with suspected (nonhistological)
diagnosis of adenomyosis, after insertion of a
levonorgestrel-releasing intrauterine
system, VEGF expression is substantially
reduced in eutopic endometrial glands and
stroma; however, it is not known whether
the same occurs in the heterotopic glands.

67. • Another approach aimed at inhibiting angiogenesis
has been studied by the group of Creatsas using
pentoxiphylline, a phosphodiesterase inhibitor.
In an animal model, they evaluated changes in
morphology and in the expression of VEGF-C and of
the receptor for tyrosine kinase, Flk-1 (a VEGF
receptor) and observed a significant reduction in the
mean volume of the endometriotic implants per
animal when compared with the control group. Their
conclusion was that pentoxiphylline may cause
suppression of endometriotic lesions by suppressing
angiogenesis through VEGF-C and Flk-1 expression.

68. Creus et al
• In a prospective, randomized, controlled, blind trial, a
group of patients was randomly assigned, immediately
after laparoscopic surgery, to treatment with either oral
pentoxiphylline (800 mg/day) or an oral
placebo. These women were then observed for the
occurrence of pregnancy for 6 months. In the approximate
100 patients who completed the study, the 6-month
overall pregnancy rates were 28 and 14% in the
pentoxiphylline and placebo groups, respectively (p = 0.1).
These findings provide preliminary clinical evidence to
suggest that new experimental treatment approaches
toward endometriosis, that are based on
immunomodulation deserve further attention. Well-
designed multicenter trials are warranted to confirm or
refute these results

69. In late 1980’s
Steinleitner even suggested
that, "the periovulatory
administration of nonteratogenic
immunomodulatory agents may
provide an alternative to
conventional treatment for
endometriosis."

70. A True Help for Adenomyosis

71. Can Adenomyosis be treated without
surgery?
Some studies have shown that there is a
relationship between Adenomyosis and
hormone imbalance, most commonly an excess
of estrogen. Progesterone therapy, either in the
natural or synthetic form has been known to
help, but shows very little long term benefits.
Danazol may be helpful in treating the pain and
decreasing the size of the uterus but long term
positive results are poor.

72. Xeno estrogens
Chemical estrogens known as xenoestrogens (xeno
means foreign) first came to widespread scientific
attention in the early 1990’s. The cover story of TIME
magazine October 30, 2000 told of young girls going
through early puberty. The famous 1997 Herman-
Giddens study showed that out of 17,000 girls aged
8, 15% of these girls aged 8 were sprouting breast
buds and pubic hair. TIME magazine blamed
chemicals that act like estrogen or xenoestrogens for
causing the early puberty. These same chemical
estrogens, xenoestrogens, that are causing early
puberty in girls are now being blamed as the cause of
adenomyosis as well as endometriosis, breast cancer
and cervical cancer.

73. Natural Hormone Treatment of
Adenomyosis
Natural Progesterone opposes the effect of estradiol and
xenoestrogens. Estrogen tells the cells to reproduce and
proliferate. Natural Progesterone tells the cells to stop
reproducing and grow up and mature. Excess estrogen or
estrogen dominance encourages endometrial growth!
Thus, excess estrogen in the form of estradiol and chemical
estrogens will cause adenomyosis and endometriosis to get
worse.
The solution for adenomyosis is to avoid xenoestrogens
( chemical estrogens ) and then take Natural Progesterone. By
taking Natural Progesterone, we are creating what is known in
the mainstream medicine as a "pseudo pregnancy" or false or
fake pregnancy.

74. • Natural Progesterone is NOT the same as the
synthetic prescription Progestin
• These synthetic prescription Progestins are
chemically modified from Natural Progesterone.
• This is because any hormone found in nature, by
law, cannot be patented.
• Thus, if something cannot be patented, then
there are 30 competitors.
• The price goes down.
• Patented Progestins are patented.

75. Plan of treatment
Usually, I recommend my patients to make a change to avoid
xenoestrogens in their soaps, shampoos and laundry detergent, etc.
for 1-2 months, and THEN take Natural Progesterone. This waiting
time allows the xenoestrogens to wash out of the body. Chronic
excess estrogen exposure makes the human body desensitized to
estrogen. It is sort of like going to a rock concert. In the
beginning, the music is loud, but after half an hour, the music seems
not so loud. The music loudness has NOT changed, your body has just
tried to become less sensitive to the noise. Similarly, the body
becomes less sensitive to estrogen because of the chronic excess
estrogen exposure.
Natural Progesterone resensitizes the estrogen receptors back to
normal. And it seems like you are getting more estrogen when you
are really not.
For most cases, cutting out the xenoestrogens for 1-2 months and
THEN taking Natural Progesterone works well for adenomyosis. This
allows time for the xenoestrogens to wash out of the body. The rare
exceptions to this rule are women with chronic levels of anxiety or
fear that retain xenoestrogens and have an extreme "clogged toilet"
syndrome

77. How can Female Alternative Surgery
help Adenomyosis?
• Most commonly, hysterectomy has been the mainstay of
treatment. Traditional medicine states that since most women
with Adenomyosis are beyond child-bearing age, the uterus is no
longer relevant. At the Institute, we want to give women every
opportunity to retain their female organs even if fertility is not a
concern. Our surgical approach is first to make a diagnosis. For
women who still wish to conceive, we try to remove the
Adenomyosis using laser technology (CO2 Yag and Argon) which
preserves the endometrial cavity but treats the remaining deep
uterine muscle disease. In the case of women who are not
concerned with fertility but want to preserve their organs, our
approach is to remove as much of the affected tissue and, if
necessary, decrease the size of the endometrial cavity. We treat
the remaining uterine muscle with a deep tissue laser technique.
Post surgical results have shown that pain almost always
disappears and menstrual flow and volume decrease.

78. Remember: Every form of
treatment should be tried
before a hysterectomy is
ever considered.

79. Still after so many options………
the dilema & frustration of an
ideal treatment for adenomysosis
persisits,specially in women
where uterus has to be conserved

80. thank you for hearing me out…..
Invite you all for…..
International
Society of
Ultrasound in
Obstetrics and
Gynecology
(ISUOG)
8 International
Symposium
India 2012
th
May 31 - June
3, 2012
Taj Palace
Hotel, New
Delhi