Endometriosis

Question 1

Viable fragments of endometrial tissue is refluxed through the fallopian tube–> implants elsewhere in pelvis
* most widely accepted theory

Answer 1

Retrograde menstruation theory

Question 2

what must be considered in any woman of reproductive age with CPP or infertility (dysmenorrhea or dyspareunia)

Answer 2

endometriosis

Question 3

when should a physical examination be done for endometriosis?

Answer 3

just before or during early menses (implants largest, most tender, most active, symptoms most severe)

Question 4

what are the five most common sites of endometriosis in order?

Answer 4

1. ovaries
2. cul-de sac
3. uterosacral ligament
4. broad ligaments
5. fallopian tubes

Question 5

what does definitive diagnosis of endometriosis require?

Answer 5

visualization and histologic confirmation (biopsy)
laparoscopy = visualization

Question 6

symptoms of endometriosis are dependent on?

Answer 6

location, extent, depth of endometriotic lesions, and adhesions

Question 7

staging for endometriosis is based on?

Answer 7

location, diameter, depth (superficial vs. deep) and density (quantity) of EM lesions
endometriomas
adhesions

Question 8

what is typically first line treatment for endometrosis?

Answer 8

medical therapy is typically 1st line

Question 9

what are the first line medications for endometriosis?

Answer 9

NSAIDs, acetaminophen, antidepressants
OCPs
Progestins

Question 10

what are second line medications for endometriosis?

Answer 10

GnRH agonists, antagonist
androgenic agent: danazol
antieestrogenic, antiprogesterone, androgenic agent

Question 11

what is the use of OCPs in endometriosis?

Answer 11

used based on the observation that pregnancy provides pain relief and decreases # and size of endometrial implants
slows growth
decreases possibility of tissue reflux

Question 12

why the use of progestin in endometriosis?

Answer 12

Decrease estrogens, decrease menstrual flow;
oppose growth promoting effects of estrogen;
decrease estrogen receptors;
convert estradiol to estrone;
decreases cyclic bleeding

Question 13

what are the most common progestins?

Answer 13

Medroxyprogesterone acetate
-depo provera
-dienogest
-megestrol acetate
-norethindrone acetate
-levonorgestrel- releasing intrauterine system

Question 14

what is the mechanism of action of GnRH agonists?

Answer 14

inihibit LH/FSH release from pituitiary gland
-prevent ovulation and menstruation
-EST levels similar to menopausal levels with amenorrhea; pseudo-menopause

Question 15

what is the mechanism of action of GnRH antagonist?

Answer 15

inhibit GnRH receptors in the pituitary–> decrease FSH and LH decreasing estrogen and progesterone
* have to use a barrier method for contraception

Question 16

what is the mechanism of action of Danazol

Answer 16

its a testosterone derivative
* leads to atrophy of endometrial implants
* must prevent pregnancy, will harm embryo
* cannot use OCPs at same time

Question 17

which surgery is good for treating mild to moderate cases of endometriosis?

Answer 17

laparascopy

Question 18

which surgery is good for treating deep, infiltrating lesions?

Answer 18

laparotomy

Question 19

why is laparoscopy often better?

Answer 19

decreased adhesion formation (overall 35-70%) with laparscopy

Question 20

how does endometriosis cause infertility

Answer 20

poor ovarian reserve (decreased oocyte production)
decreased oocyte quality
disturbance of ovulation
decreased fertilization
etc.

Question 21

true or false: infertile patients often have no painful symptoms?

Answer 21

true

Question 22

early stage EM should be treated how? if the the patient wants children

Answer 22

surgery +supraovulation

Question 23

advanced disease for a patient who wants kids should be treated how?

Answer 23

Surgery + IVF

Question 24

ectopic endometrial tissue found within the uterine myometrium. Leads to hyperplasia and hypertrophy

Answer 24

Adenomyosis

Question 25

what physical findings would you expect in adenomyosis?

Answer 25

high normal or enlarged, globular uterus; may be diffuse or nodular (resembling fibroids; tender uterus

Question 26

how do you diagnose Adenomyosis?

Answer 26

Enlarged uterus and thickened junctional zone present on MRI
definitive dx- often by pathology/ microscopy (often at hysterectomy)

Question 27

treatment of adenomyosis?

Answer 27

OCPs in conjuction with NSAIDs and GnRH agonists for symptomatic relief
uterine artery embolization in women who have completed child-bearing
definitive surgery with hysterectomy (preserve ovaries if younger patient)

Question 28

what does adenomyosis increase the risk of?

Answer 28

Increased risk of preterm birth
increased incidence of preterm labor and premature rupture of membrane
risk of uterine rupture