Flashcards in Endometriosis Deck (27)
Chronic, benign, estrogen dependant condition where endometrial glands + stroma are found outside the endometrial cavity.
There are 6 main theories regarding the cause of endometriosis. What are they?
1. Endometrium reflux back through tubes and then grows onto pelvic structures
2. Coelemic meatplasia
3. Embryonic remnant theory
4. Surgical transplantation - CS sites or Lap sites
5. Haematogenous/Lymphatic spread
6. Trans-coelemic spread
What are the 2 most common locations of endometriosis to be found?
Uterosacral ligament and peritoneum of the Pouch of Douglas
What are the 3 main clinical features associated with endometriosis?
1. Pelvic Pain - due to direct stimulation of sensory nerves + adhesion formation
Subfertility is a problem associated with endometriosis. Why?
1. Adhesions - blocking the path of the ovum
2. Dysparenua - inability to have sex due to pain
3. Change in peritoneal fluid --> toxic
What are some other clinical features based on the various locations of the anastamoses. e.g bladder or intestinal
Bladder --> increased frequency, increased urgency and haematuria
Intestinal --> change in bowel habit OR dyschezia (pain on opening bowels)
What will be found on examination of a patient with endometriosis?
- Bimanual examination may revel tenderness, fixation and nodularity in the Pouch of Douglas.
- tenderness on palpation of uterosacral ligaments + tightening
- in majority of patients -> no obvious clinical signs though
Explain the role that oestrogen and progesterone play in the endometrium.
Oestrogen - growth/proliferation of endometrium
Progesterone - INHIBITS proliferation + makes endometrium secretory
if oestrogen + progesterone = progesterone inhibits endometrial proliferation
if NO oestrogen or progesterone (premenarche or menopause) = no endometrial growth -> no endometriosis
What 3 investigations can be carried out in the setting of suspected endometriosis? One of these is the gold standard.
Gold Standard: Laproscopy for diagnosis and determining extent of disease
- MRI to find deep lying endometriosis involving the bowel
- Preoperative high res U/S = laprascopic findings
Name 4 differentials to be excluded when suspecting a patient to have endometriosis.
2. Primary dysmenorrhoea
4. GIT diseases
What are the two main considerations when discussing the management of this patient with endometriosis?
Symptoms and Fertility Status. If patient is trying to conceive its necessary to have surgical management because medical management is basically a contraceptive.
What are the 3 main goals of medical management of a patient with endometriosis?
1. Inhibition of PG synthesis
2. Effective decidualisation
3. Atrophy of ectopic endometrium
What are the 4 main options when it comes to the medical management of endometriosis?
3. Oral Progestins/Injectable Progestin/Progestin implant
4. GnRH analogue/danazol
How do NSAIDs work in managing this condition?
Decreased PG synthesis -> Decreased vigourous contractions of the uterus which means decreased discomfort.
How does the OCP work in managing this condition?
OCP suppresses ovulation. Reduces growth of endometrial tissue. Increases apoptosis of ectopic endometrium.
How do progestins (in all their forms) work to manage this condition?
Inhibition of endometrial growth. Direct effect of causing decidualisation and atrophy. indirect via decrease in endogenous oestrogen through inhibition of hypothalmic pituitary axis.
How do GnRH analogues/danazol work to manage this condition?
Suppresses the hypothalmic-pituitary-axis.
What are the side effects of no estrogen (GnRH analogue)?
4. Adverse lipid profile
What are the side effects of increased androgens (danazol)?
3. Weight gain
4. Voice change
Put simply, what are the goals of surgical treatment of sites of endometriosis?
1. Resect it
2. Burn it
3. Hysterectomy - will stop new retrograde endometriosis
4. Castration - remove ovaries because of the hormones it produces and it is essentially the same as the GnRH analogues but long term
Mx scenario: big endometrial cyst
Mx scenario: if want pregnancy
Mx scenario: dotting + splits
Mx scenario: older, have many symptoms, finish child bearing, finish other treatment
Mx scenario: younger patients, not kids now, no cysts
Mx scenario: older patient, milder disease