Endometrial diseases

Question 1

Endometriosis

Answer 1

Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature.

Question 2

Clinical features of endometriosis

Answer 2

Dysmenorrhea (progresses to acyclic)
Chronic/cyclic pelvic pain
Dyspareunia
Subfertility
Uterosacral ligament nodularity (guitar string tenderness)
Fixed retroverted uterus
Depression

Question 3

Key investigations

Answer 3

Transvaginal ultrasound may show ovarian endometrioma (homogenous low-level echoes) or deep pelvic endometriosis (hypoechoic linear thickening)

Laparascopy indicated if:
NSAID resistant lower abdo pain
Pain missing school/work
If concerns of infertility

Question 4

Endometriosis: Treatment if fertility required

Answer 4

Clomifene (anti-oestrogen) or letrozole (aromatase inhibitor)
or
IVF and therapeutic laproscopy

Question 5

Endometriosis: Treatment if fertility not required. endometrioma or suspected deep disease

Answer 5

Surgery

GnRH agonist, progestogen

Question 6

Endometriosis: Treatment if fertility not required. No Endometrioma or suspected deep disease

Answer 6

1. COCs with NSAIDs
2. GnRH agonist
3. Progestogens

Question 7

Adenomyosis

Answer 7

Extension of endometrial tissue and stroma into the uterine myometrium

Question 8

Diagnosing adenomyosis

Answer 8

Transvaginal US
MRI Scan
Histology after hysterectomy

Question 9

Risk factors for adenomyosis

Answer 9

40-50s
Parity (women who have had children))
Prior uterine surgery

Question 10

Clinical features of adenomyosis

Answer 10

Abnormal uterine bleeding
Dyspareunia
Dysmenorrhea
Often asympotomatic uterine is symmetrically enlarged and tender

Question 11

Management of adenomyosis

Answer 11

COCs or progestins such as mirena (IUS)
NSAIDs
Hysterectomy
GnRH agonist (D+C necessary to exclude endometrial carcinoma

Question 12

Endometrial hyperplasia

Answer 12

Endometrial thickening with proliferation of irregularly sized and shaped glands

Question 13

Common cause of hyperplasia

Answer 13

Exogenous oestrogen

Question 14

Risk factors for hyperplasia

Answer 14

50-70 Years
Obesity
Nulliparity, early menarche, late menopause
Oestrogen replacement therapy (Tamoxifen)
PCOS
T2DM
Granulosa cell tumour

Question 15

Classifications of endometrial hyperplasia

Answer 15

Simple No Atypia 1%
Simple Atypia 8%
Complex No Atypia 3%
Complex Atypia 29%

Atypia is abnormal cell
%= chance of malignancy

Question 16

Clinical feature of endometrial hyperplasia

Answer 16

Abnormal Uterine Bleeding

Question 17

Key investigations of endometrial hyperplasia

Answer 17

Endometrial biopsy
Pelvic and transvaginal US 2-3 days after menstruation (thinnest). 4-7mm
Repeat ultrasound
D&C

Question 18

Management of endometrial hyperplasia

Answer 18

No Atypia-Progesterone (oral/IUD)

Hysterectomy