#397 ‒ Endometriosis and adenomyosis: diagnosis, fertility, reproductive aging, and emerging treatments | Renato Tomioka, M.D., Ph.D.

What It Covers

Reproductive medicine specialist Renato Tomioka explains endometriosis and adenomyosis — conditions affecting 10% and 20–30% of women respectively — covering the 5–12 year diagnostic delay, how MRI and specialized ultrasound have replaced surgical diagnosis, hormonal versus surgical treatment decisions, IVF pathways, and how female age drives a nonlinear rise in chromosomal abnormalities that makes egg timing critical.

Key Questions Answered

• •Diagnostic delay and its consequences: The average woman waits 5–12 years for an endometriosis diagnosis in the US (6 years) and Brazil (7 years). This delay directly causes central pain sensitization — where the nervous system rewires so that even after successful surgery, pain persists. The ACOG's 2025 guidance now allows clinical diagnosis based on symptoms alone, permitting earlier empirical treatment without requiring surgical confirmation via laparoscopy.
• •The "6 D's" symptom framework: Endometriosis presents across six categories: dysmenorrhea (severe period pain requiring IV medication), deep dyspareunia (pain during intercourse), dyschezia (pain during bowel movements), dysuria (cyclic urination pain), difficulty conceiving, and dysfunctional chronic pelvic pain lasting over 6 months. Up to 10% of patients are entirely asymptomatic, with infertility as their only presentation. Adenomyosis more commonly causes heavy uterine bleeding leading to anemia.
• •Modern imaging replaces surgical diagnosis: Standard transvaginal ultrasound has very low sensitivity for endometriosis. The correct diagnostic approach uses either a detailed bowel-prep ultrasound protocol (one-hour exam with enema prep, developed in Brazil) or pelvic MRI with T1/T2 sequences — both achieving 95–98% sensitivity and specificity. MRI is superior for diaphragm and ureteral lesions; the specialized ultrasound is better for bowel endometriosis. Planning surgery without one of these is inadvisable.
• •Aneuploidy rates by age are nonlinear and worse than assumed: At age 31, roughly 30–35% of blastocysts are chromosomally abnormal. By 38, that figure reaches 60%; by 40, approximately 70%; and by 42, around 85%. Counterintuitively, very young women (around age 20) also show elevated aneuploidy rates, with the lowest risk occurring near age 25. This J-curve means a 35-year-old woman pursuing IVF may need multiple cycles simply due to chromosomal inefficiency, not structural infertility.
• •Adenomyosis reduces IVF live birth rates by ~30%: Adenomyosis — endometrial tissue invading the uterine muscle — causes contractions in the junctional zone that expel implanted embryos, typically at 6–8 weeks. Junctional zone involvement triples miscarriage risk. Treatment involves 2–4 months of GnRH agonists (leuprolide or goserelin) before frozen embryo transfer, which normalizes implantation and miscarriage rates. Oral GnRH antagonists (elagolix, relagolix) are equally effective but cost approximately $1,000 per month in the US.
• •Surgical mistakes that harm fertility: Three common surgical errors: (1) Operating on patients with central pain sensitization, where surgery cannot address neurological rewiring — pelvic floor physiotherapy 8 weeks pre-surgery is required. (2) Removing endometriomas before egg retrieval — cystectomy reduces AMH by 40–50% because follicles are stripped alongside the cyst wall. Harvest eggs first, then operate if cysts exceed 5–6 cm. (3) Leaving a damaged hydrosalpinx tube in place — its cytotoxic fluid reduces IVF success rates by 50%, requiring salpingectomy.
• •Modern menstruation patterns drive endometriosis prevalence: Two hundred years ago, women averaged roughly 100 lifetime ovulatory cycles due to later menarche (age 16 vs. 12 today), earlier first pregnancy (age 20 vs. 30+), multiple pregnancies, and extended breastfeeding. Modern women average approximately 400 cycles — a fourfold increase in retrograde menstruation events. Each cycle carries risk of endometrial tissue seeding the pelvis. Continuous hormonal suppression (oral contraceptives, progestin-only pills, or Mirena IUD) mimics the historical pattern and reduces disease progression.