Endometriosis Flashcards Preview

Obstetrics and Gynaecology > Endometriosis > Flashcards

Flashcards in Endometriosis Deck (18):
1

Incidence, in all/infertile/chronic pelvic pain

Later reproductive life
30-45
4-10% all repro women
20-25% infertile women
80% of those with chronic
pelvic paiin

2

Infertility Pathology

Infertility-->
ovulation in closed off area
damage to fimbrae
kinking of tubes by adhesions
blockage of tube by deposits of
endometriosis in wall, embrotoxicity,
interfered normal ovulation/steroidogenesis

3

Sites of endometriosis

Pelvis, ++uterosacral ligaments
and
++ Ovaries (cysts)
Peritoneum-->adhesions
Bowel-->obstruction
Ureters/urethral-->hematuria,
dysuria
Bowel-->adhesions, obstruction
Uterine ligaments, tube,
rectouterine, pouch of douglas
Abdominal wall

4

Types (4)

Superficial
Deep infiltrating>5mm
Endometriomas
Adenomyosis

5

Symptoms

Infertility
Disturbance of mensturation
Pain
Hematuria, dysuria
Intestinal obstruction
Acute abdomen
Dyschezia
Dysparaneuria
Dysmenorrhea->not relieved by NSAIDs

6

Pathogenesis

1. Retrograde mensturation
2. Immunological theory
3. Abnormal proliferation
4. Direct spread
5. Metaplasia

Emboli, totipotent cells
Failure of immune recognition
of emboli
Retrograde spread-->
– Menorrhagia
– Cervical stenosis
– Outflow tract obstruction

Portions of endometrium
outside-->cyclical changes,
+inflammation, fibrosis when
attaches to organs

– Endometrial type
glands
– Endometrial type
stroma
– Evidence of cyclical
activity (recent or old
blood)

7

Pain-cause, location, dysparaneuria

Pain-->
congestive: lower back, pelvis at
mensturation
Ovulation pain mid cycles
Dysparaneuria-->deep pelvis,
pressure on uterosacral ligaments
and rectovaginal septum in coitus

8

Physical examination

Single digit + bimanual examination
Pelvic mass (endometrioma)
Fixed and retroverted uterus
Utersacral nodularity, tenderness

9

Risk factors

Family history
Reproductive age group
Nulliparity
Mullerian anomalies

Weak:
White
Low BMI
Autoimmune
Late first sexual encounter
Smoker
Previous cesaerean

10

Investigations

TVUS->endometrioma
Diagnostic laparoscopy gold standard

11

Management

Fertility not desired:
NSAID + paracetamol
COCP is first line
-progestins, Mirena,
GnRH agonists (leuprorelin),
danazol,
aromatase inhibitors?
1/3 no response,
may have SEs

If endometrioma->laparoscopy

If +for fertility:
Controlled ovarian hyperstimulation with lomiphene
Second line is IVF
Therapeutic laparoscopy

12

Does medical management improve fertility, laparoscopy, IVF as option

Medical-> not improved fertility
Laparoscopy improves
IVF not good option

13

What can be done at laparoscopy

Lap to ablate,-->
excise to leave less residual,
diathermy unstable (risk harm to
adjacents), ++pain releif
lyse adhesions, remove
endometriomas,
uterosacral nerve
ablation,
presacral neurectomy

14

When is lap indicated

In all infertile women ?

15

Benefits of laparoscopy

Higher pregnancy rate
Better long term prognosis
Early diagnosis allows more focused care
Diagnose and treat in one sitting
Quick recovery
Can stage the disease

16

Pregnancy rate following treatment with laparoscopy

10-20%

17

Classification of mild vs severe

Mild: no compromised fallopian tubes or ovaries
Severe: extensive adhesions, altered organ function

18

Endometriosis and mood

+depression
Need to ask history of mood disturbance, look for evidence of depression