Chapter 31: Endometriosis

Question 1

What is endometriosis?

Answer 1

Endometriosis - Presence of endometrial glands and stroma outside of the uterus

Question 2

How do we diagnose endometriosis?

Answer 2

Dx: Tissue biopsy, usually s/p laparotomy, often for other conditions as women are often
asymptomatic

Question 3

Endometrial cysts respond to ______

Answer 3

hormone changes

Question 4

Is endometriosos linked genetically?

Answer 4

Yes. Women with first degree relatives with endometriosis are 10x as likely to get it

Question 5

Describe the retrograde theory of how we get endometriosis

Answer 5

Retrograde menstruation that causes deposition of endometrial cells in other locations

(Direct implantation theory by Sampson)

Question 6

Retrograde theory does not explain how we get tissues in distant locations. Which theory does?

Answer 6

Vascular/Lymphatic dissemination (Halban Theory)

Explains cells being in distant locations

Question 7

How do men or pre-menopausal women get endometriosis?

Answer 7

Coelomic metaplasia of multipotential cells of the peritoneal cavity (Meyer theory). Under certain conditions, these cells can develop into functional endometrial tissue. Explains how some adolescents before menstruation get endometriosis

Question 8

Most common site for endometriosis?

Answer 8

Most commonly found in the ovaries bilaterally.

Other common sites are the pouch of douglas or posterior culdesac, particularly the uterosacral ligaments. Rarely, other distant organs like the
lungs, brain, upper uterus

Question 9

4 most common appearences of endometrial tumors

Answer 9

i) Small 1mm clear or white lesion
ii) Small dark red “mulberry” or brown “powder burn” lesions.
iii) Cysts filled with dark red or brown hemosiderin-laden fluid (“chocolate cysts”)
iv) Dark red or blue “domes” that reach 15-20 cm.

Question 10

Presentation for endometriosis

Answer 10

Classic: Progressive dysmenorrhea, infertility, and deep dyspareunia. May be associated with chronic pain if adhesions are present.

Infertility - No idea why yet. Present in 30-50% of asymptomatic infertility

Dysmenorrhea that does not respond to NSAIDs or OCPs is a clue

Less common: Dyschezia - Painful bowel movements. Sometimes with acute abdominal emergency secondary to a ruptured endometrioma

Question 11

Possible physical exam finding for endometriosis

Answer 11

Anatomically: Uterosacral nodularity or a fixed uterus due to adhesions

Question 12

Specific diagnostic threshold for biopsy

Answer 12

2 or more of the following: Endometrial epithelium, endometrial glands, endometrial stroma,hemosiderin-laden macrophages

Question 13

Discuss the current state of affairs for other means of diagnosing endometriosis besides just with an invasive biopsy

Answer 13

b) People looking into other less invasive ways, looking at CA-125 elevation seen in moderate to severe endometriosis, but this can be seen in cancer, fibroids, and a host of other things, so not all that helpful yet
c) Imaging: US/CT/MRI only helpful if there is a pelvic or adnexal mass. US can see ovarian endometriomas which typically appear as homogenous old-blood echos. MRI lacks rectal sensitivity but good for uterosacral and cul-de-sac lesions

Question 14

How do we stage endometriosis?

Answer 14

Staging: Stage I to IV, minimal to severe. Based on points (1-5) (6-15) (16-40) (>40)

Question 15

Overall goals of treatment for endometriosis

Answer 15

Goals: Reduction in pelvic pain, minimizing surgical intervention (TAH with BSO associated with a 10% risk of recurrent symptoms and 4% chance of recurrence), and preserving fertility.

Question 16

Discuss the expectant management approach for endometriosis

Answer 16

Expectant management: Limited disease or no symptoms. Young may do it to preserve fertility. Older who have not had menopause may wait to see if decrease in hormones may decrease symptoms

Question 17

When can medical management be used for endometriosis

Answer 17

Medical: Responds to both exogenous and endogenous hormones . Medical effectiveness is based on its ability to atrophy the mass. Great for patients who want to become pregnant but are symptomatic. Not good for adhesions or fibrosis already there and it’s likely that the masses will recur. Can be done even if you haven’t visualized masses if you’ve eliminated other possibilities.

Question 18

Main medical management technique for endometriosis

Answer 18

Oral Contraceptives: Great for restoring cycle and shrinking masses. Progesterone therapy as subcutaneous depot medroxyprogesterone acetate (DMPA) or implants, suppresses
gonadotropic release and in turn ovarian steroidogenesis. It also directly affects uterine endometrium and uterine implants.

We see a temporary (12 months) dip in bone density that restores. Doesn’t stop pregnancy, so take it if you still want to get pregnant.

Question 19

Besides OCP use, what else can we use for medical management of endometriosis?

Answer 19

Danazol - Suppresses LH, FSH midcycle surges, so ovary no longer makes estrogen, causing amenorrhea and uterine atrophy. Side effects are because of lack of estrogen: acne, spotting and bleeding, hot flashes, decreased libido, atrophic vaginitis

GnRH agonists: Down-regulate pituitary to slow down LH and FSH

Question 20

Surgical management for endometriosis?

Answer 20

Take away the uterus.