Dysmenorrhea/Endometriosis

Question 1

Initial mx of dysmenorrhea

Scenario 1 - adolescent, painful periods

Scenario 2 - 12yo, painful periods since menarche @9yo

Scenario 3 - 16yo, menarche since 13yo, painful periods, FHx of Endo

Scenario 4 - 13yo, painful periods worsening since menarche @12yo

Answer 1

DDx (CPP)
- Endometriosis
- STI/PID
- Congenital anomalies
1. imperforate hymen
2. transverse septum
3. bicornuate ut with non-communicating horn
4. didelphys + septum

• risk of undiagnosed PID/infertility
• risk of psychosocial
• MSU/STI screen/COGU pelvic USS
  +/- renal tract USS
• trial of COCP + NSAID
• chase investigation
• F/U in 3/12 -> refractory -> PAG -> diagnostic lap +/- rx

Question 2

Definitive mx of MD anomaly

Scenario 1 - incidental finding on diagnostic laparoscopy - bicornuate uterus with non-communicating horn

Scenario 2 - uterine didelphys on pelvic USS

Answer 2

• risk to health/fertility - endo/adhesion
• M risk - ectopic/rupture/CS
• F risk - MC/FGR/malpresentation
• MRI +/- renal tract USS
• Refer to PAG @ Tertiar
• R/O non-com horn or hemi-hyster
• Postop F/U, resolution of sx

Question 3

Mx of endometriosis

Scenario 1 - adolescent, painful periods - incidental finding on lap

Scenario 2 - 12yo, painful periods since menarche @9yo - incidental finding on lap

Answer 3

• risk to fertility - transport factor
• risk to pain/psychosocial
• MDI-Gyn/PT/Psych/Pain
• medical vs surgical
• medical - hormonal suppression
• surgical - improve pain/conception
• 30% recurrence w optimal excision
• ? evidence for early rx & LT benefits
• ongoing rx depends on sx & fertility

Question 4

Mx of rectovaginal endo nodule

Answer 4

• risk of persistent sx vs stoma
• further imaging - MRI +/- Colonoscopy
• refer tert - expertise
• MDT - with CR involvement
• Consent include temp colostomy
• Bowel prep pre-op

Question 5

Mx of post-endo surgery pain

Scenario 1 - pt p/w ongoing neuropathic pain & dyspareunia post lap rx of endo + mirena insertion

Scenario 2 - post rectovaginal excision of severe endo, returns with LIF pain 6/12 post-surgery

Answer 5

DDx
1. bowel injury/collection (if recent)
2. new lesion (if no hormone suppress)
3. central/peripheral sensitization

• risk of sepsis/decompensation
• exclude intra-abdo infection
• FBE/CRP/CTAP
• Admit/NBM/IVT pending Ix
• MDI - Gyn/PT/Pain/Psych
• exclude acute cause
• advise multi-modal mx
• advise hormonal suppression