Endometriosis Flashcards
(7 cards)
What is Endometriosis?
A condition caused by misplaced endometrial cells.
* oestrogen causes proliferation of endometrial tissue.
* in the luteal phase, progesterone stimulates the development of glandular structures which cause an increase in the volume of this
* During menstruation; tissue goes into the pelvic cavity, bleeding also happens in the pelvic cavity or between the muscles fibres of the uterus (adenomyosis)
Many people with this also develop ovarian cysts - chocolate cysts
What causes Endometriosis and what are the risk factors?
Pathophysiology; it is poorly understood, but
multiple mechanism involved:
* Early on in endometriosis; high levels of inflammatory cytokines, lymphocytes and macrophages.
* Later on; macrophage activity is reduced
* Over time; hormonally stimulated endometriosis by upregulation of aromatase, which causes an increase in prostaglandin E2, so muscle spasm, inflammation, dilation of blood vessels and blood loss
Risk and contributory factors
* Retrograde menstruation is thought to be the most common reason (where blood flows back into fallopian tubes)
* Severe dysmenorrhoea; extreme contractions increase retrograde flow as well as prostaglandin imbalance.
* Strenuous exercise
* IUCD increases the risk
Immune system involvement is also suspected - reduced ability to detect and clear cells
* Natural killer cell activity is reduced, linked to higher oestrogen levels.
* Macrophages reduced ability to clear away apoptotic cells
* Apoptosis activity reduced
* High rates of autoimmune and atopic diseases among women with endometriosis.
Local inflammation is also involved - causes proliferation, apoptosis, adhesions, and angiogenesis.
Its v complex!!
Hormonal involvement also contributing too: Oestrogen relative excess - too much and also lack of progesterone
* Endometrial cysts and ectopic endometriotic lesions; high levels of aromatase found lower levels of 17beta hydroxysteroid dehydrogenase type 2 in endometriosis this enzyme converts oestradiol into the weakly oestrone.
* Oestrogens activate macrophage, causing induction of production of proinflammatory cytokines.
* Progesterone resistance
Other contributing factors leading to oestrogen excess.
* Environmental. Exposure to pesticides, plastics etc….
* Tampons: Dioxin is a by-product of the chlorine bleaching process, studies are conflicting
* Higher incidence in former OCP users
* Smoking appears to reduce risk.
* Gut microbial diversity is higher in controls compared to patients with endometriosis.
* Obesity; predisposes to a pro-inflammatory state, and oestrogen dominance
What are the signs and symptoms of Endometriosis?
Symptoms; there is no relationship between the extent of the lesions and the severity of symptoms, some asymptomatic
* Typical age of onset: 12-30
* Dysmenorrhoea: severe & debilitating - interferes with day to day activity
* Infertility
* Chronic pelvic pain
* Dysparunia
* Menorrhagia
* Commonly there is no relief with nonsteroidal antiinflammatory drugs (NSAIDs) or oral contraceptive therapy.
* Pain on defecation/urination
* Endometrioma (cysts also grow); tendency to rupture, acute adominal pain
What is common differential diagnosis?
Only way to diagnose is with a laproscopy. Sometimes there may be DDx:
* pelvic inflammatory disease
* sexual transmitted diseases (Chlamydia, gonorrhoea)
* GIT issues including appendicitis
* ovarian cysts leading to torsion
* urinary tract infections
Why is infertility a complication?
Infertility is the third major sign of endometriotis, with dymenorrhea and dysperinia. Infertility is due to several mechanisms:
* scarring and adhesions as consequence of inflammation
* disturbed folliculogenesis
* luteinised unruptured follicle
* luteal defect
* progesterone resistance
* anti-endometrial antibodies
* disfunctional uterotubal motility
* excessive amounts of free radicals
* changes cytokine profiles
* Immune system deficiency
What is conventional treatment for endometriosis?
Conventional treatment
* The combined oral contraceptive pill - stops ovulation and makes periods lighter
* Progestogens - prevent tissue growing so quickly
* Gonadotropin-releasing hormone
(GnRH) analogues - creates a menopause, but can’t do it long term
* Laparoscopy: endometriosis tissue
can be destroyed or cut out via surgery
* Hysterectomy
