5. Endometriosis

Question 1

Define: Endometriosis (2)

Answer 1

• the presence of endometrial tissue (glands and stroma) outside of the uterine cavity
• chronic condition, resolving only with menopause

Question 2

Name ddx of endometriosis (4)

Answer 2

• Chronic PID, recurrent acute salpingitis
• Hemorrhagic corpus luteum
• Benign/malignant ovarian neoplasm
• Ectopic pregnancy

Question 3

Name etiologies: Endometriosis (4)

Answer 3

• not fully understood; proposed mechanisms include (combination likely involved):
  
  • retrograde menstruation (Sampson’s theory)
  • immunologic: decreased NK cell activity limiting clearance of transplanted endometrial cells from pelvic cavity (may be due to decreased NK cell activity)
  • metaplasia of coelomic epithelium
  • extrapelvic disease may be due to aberrant vascular or lymphatic dissemination of cells
    
    • e.g. ovarian endometriosis may be due to direct lymphatic flow from uterus to ovaries

Question 4

Describe epidemiology: Endometriosis (3)

Answer 4

• incidence: 15-30% of pre-menopausal women
• mean age at presentation: 25-30 yr
• regresses after menopause

Question 5

Name risk factors: Endometriosis (4)

Answer 5

• family history (7-10x increased risk if affected 1st degree relative)
• obstructive anomalies of the genital tract (earlier onset) – resolves with treatment of anomaly
• nulliparity
• age >25 yr

Question 6

Name: Classic Triad of Endometriosis

Answer 6

• Dysmenorrhea
• Dyspareunia (cul-de-sac, uterosacral ligament)
• Dyschezia (uterosacral ligament, cul-de- sac, rectosigmoid attachment)

Question 7

Name sites of occurence of endometriosis (5)

Answer 7

• ovaries: 60% patients have ovarian involvement
• broad ligament, vesicoperitoneal fold
• peritoneal surface of the cul-de-sac, uterosacral ligaments
• rectosigmoid colon, appendix
• rarely may occur in sites outside abdomen/pelvis, including lungs

Question 8

Describe clinical features: Endometriosis (3)

Answer 8

• may be asymptomatic and can occur with one of 3 presentations
  
  • pain
  • infertility
  • mass (endometrioma)

Question 9

Describe pain in Endometriosis (7)

Answer 9

• menstrual symptoms
  
  • cyclic symptoms due to growth and bleeding of ectopic endometrium, usually precede menses (24-48 h) and continue throughout and after flow
  • secondary dysmenorrhea
  • sacral backache with menses
  • pain may eventually become chronic, worsening perimenstrually
  • deep dyspareunia
• bowel and bladder symptoms
  
  • frequency, dysuria, hematuria
  • cyclic diarrhea/constipation, hematochezia, dyschezia (suggestive of deeply infiltrating disease)

Question 10

Describe infertility in Endometriosis (2)

Answer 10

• 30-40% of patients with endometriosis will be infertile
• 15-30% of those who are infertile will have endometriosis

Question 11

Describe mass in Endometriosis (4)

Answer 11

• ovarian mass can present with any of above symptoms or be asymptomatic
• physical examination:
  
  • tender nodularity of uterine ligaments and cul-de-sac felt on rectovaginal exam
  • fixed retroversion of uterus
  • firm, fixed adnexal mass (endometrioma: an endometriotic cyst encompassing ovary)

Question 12

Describe investigations: Endometriosis (2)

Answer 12

• definitive diagnosis can be made based on:
  
  • direct visualization of lesions typical of endometriosis at laparoscopy
  • biopsy and histologic exam of specimens (2 or more of: endometrial epithelium, glands, stroma, hemosiderin-laden macrophages)
• CA-125 (cancer antigen 125)
  
  • may be elevated in patients with endometriosis but should NOT be used as a diagnostic test

Question 13

Describe laparoscopy findings: Endometriosis (5)

Answer 13

• mulberry spots: dark blue or brownish-black implants on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
• endometrioma: “chocolate” cysts on the ovaries
• “powder-burn” lesions on the peritoneal surface
• early white lesions and clear blebs
• peritoneal “pockets”

Question 14

Describe: SOGC guidelines for treatment of endometriosis (Figure)

Answer 14

Question 15

True or false

surgical confirmation of endometriosis is required prior to starting medical management.

Answer 15

False

surgical confirmation of disease is NOT required prior to starting medical management.

Question 16

Describe tx: Asymptomatic endometriosis (1)

Answer 16

does not require treatment.

Question 17

Management of endometriosis depends on what? (5)

Answer 17

• depends on certainty of the diagnosis
• severity of symptoms
• extent of disease
• desire for future fertility
• impact to GI/GU systems (e.g. intestinal obstruction)

Question 18

Describe medical tx: Endometriosis (3)

Answer 18

• NSAIDs (e.g. naproxen sodium – Anaprox®)
• 1st line
  
  • cyclic/continuous estrogen-progestin (OCP)
  • progestin (IM medroxyprogesterone (Depo-Provera®) or oral dienogest (Visanne®))
  • Mirena® IUS
• 2nd line
  
  • GnRH-agonist (e.g. leuprolide (Lupron®)): suppresses pituitary
    
    • side effects: hot flashes, vaginal dryness, reduced libido
    • use >6 mo: include add-back progestin or estrogen to prevent decreased BMD, reduce vasomotor side-effects
  • danazol (Danocrine®): weak androgen
    
    • side effects: weight gain, fluid retention, acne, hirsutism, voice change

Question 19

Describe surgical tx: Endometriosis (4)

Answer 19

• conservative laparoscopy using laser, electrocautery ± laparotomy
  
  • ablation/resection of implants, lysis of adhesions, ovarian cystectomy of endometriomas
• definitive: bilateral salpingo-oophorectomy ± hysterectomy
• best time to become pregnant is immediately after conservative surgery
• if patient is not planning to become pregnant post-op, suppress ovulation medically to prevent recurrence