Endometriosis Flashcards
Green (23 cards)
Definition of endometriosis
Presence of endometriotic tissue outside of uterus. It is hormonally driven, principally by oestrogen. Some women are relatively symptomatic with extensive disease, some have superficial endometriotic deposits with debilitating symptoms
Chronic condition found on pelvic organs outside of uterus
Who is typically affected by it?
Women of reproductive age, particularly 30-45 (some 1-2% of women)
More common in nulliparous
Those with endometriosis FHx
More common in infertile women
What is adenomyosis?
Presence of endometrial tissue in myometrium
Where does endometriosis classically deposit?
Uterosacral ligaments and on/behind the ovaries
May occasionally affect umbilicus or abdo wound scars, vagina, bladder, rectum and even lungs
What happens to the accumulated blood?
Dark brown, can form a chocolate cyst/endometrioma in ovaries (note tip of iceberg effect - on laparoscopy, a small endometriosis may infiltrate deeply)
What happens in the most severe form of endometriosis?
Causes inflammation with progressive fibrosis and adhesions; in severe form, pelvic organs rendered immobile by adhesions
Causes?
Unknown but three theories
- Retrograde menstruation (adherence, invasion and growth of tissue)
- Metaplasia of mesothelial cells (explains how tissue can appear in obscure locations e.g. nasal cavity)
- Impaired immunity (cells from retrograde menstruation fail to be destroyed by immune response; also autoimmunity)
Also Mullerian abnormalities (differentiation of coelomic epithelium into endometrial glands)
What proportion of the general population have endometriosis?
10-12% general female population estimated to have
20-50% undergoing fertility treatment/chronic pain
40-60% dysmenorrhoea
Presentations?
Pain
-Cyclical (due to endometrial tissue responding to menstrual cycle)
-Constant due to formation of adhesions from chronic inflammation
-Severe dysmenorrhoea leading to time off from work/school
-Deep dyspareunia from involvement of uterosacral ligaments
-Dysuria
-Dyschezia (pain defaecating) and/or cyclical rectal bleeding (rectovaginal nodules with invasion of rectal mucosa)
Subfertility
No symptoms (incidental factors)
Complications?
Rupture of endometriosis ovarian cysts
Examination findings?
Normal if minimal disease
Speculum - lesions of vagina/cervix (rare and sign of deep infiltrating endometriosis)
Bimanual - fixed retroverted uterus (classical sign), adnexal masses or tenderness, tender nodules palpable over uterosacral ligaments
Ix?
TVS useful for diagnosis of ovarian endometriotic cysts (but poor identifier of parameters of other disease)
MRI used if bowel involvement
CA125 may be raised
Laparoscopy with biopsy gold standard diagnosis for histological diagnosis (esp for deep infiltrating lesions)
What is looked for on diagnosis?
Active lesions are red vesicles or punctate marks on peritoneum
White scars and brown spots (powder burn) represent less active endometriosis
Extensive adhesions and ovarian endometriomas (endometrial cysts) indicate severe disease
What other differential diagnoses are possible?
Adenomyosis Chronic pelvic inflammatory disease Chronic pelvic pain Other causes of pelvic masses IBS
What is the medical management?
COCP cyclically or continuous; prostagens PO/IM/SC
Mirena IUS (laparoscopy) - suppress oestrogen-related activity for 6m to relieve symptoms
GnRH analogues e.g. goserelin short term <6m with add back HRT e.g. tibolone. Goserelin can also be used in subfertility to get IVF
Symptom recurrence common
NSAIDs - transexamic acid and Mefenamic acid may also be used (analgesia, RCT benefit inconclusive however)
What is the surgical management?
Once medical treatment failed
Laparoscopy using ablation, excision or coagulative techniques to destroy endometriosis
Nodules should be excised and endometriomas removed rather than drained (to prevent recurrence)
What happens to pregnancy rates after treatment of mild to moderate disease?
Spontaneous pregnancy rates increases with removal of lesions
Should hysteroscopy be considered?
Only as last resort
What is the surgical classification of endometriosis?
Stage 1 (minimal) -Findings restricted to only superficial lesions and possible few filmy adhesions Stage 2 (mild) -In addition, some deep lesions are present in the cul-de-sac Stage 3 (moderate) -As above, plus presence of small endometriomas on ovary and more adhesions Stage 4 (severe) -As above, plus larger endometriomas, extensive adhesions
Note that staging correlates very poorly with patient’s symptoms
What are the 5 D’s of endometriosis symptoms?
Dyspareunia
Dysmenorrhoea (postmenopausal, characteristic)
Dysuria
Dyschezia (painful defaecation)
Disorders of menstruation (Menorrhagia, IMB, amenorrhoea)
Why is it often difficult to diagnose endometriosis in community?
Lots of overlap with similar conditions e.g. IBS
What may cause continued pain in patients treated for endometriosis?
Recurrence/worsening of endometriosis
Endometrioma
Chronic pelvic pain
How is endometriosis-related infertility managed?
Suppression of ovarian function in mild/moderate endometriosis to improve fertility not effective
Ablation of endometriotic lesions plus adhesionlysis in minimal/mild endometriosis is effective
Laparoscopic cystectomy for ovarian endometrioma of uncertain benefit
Postop hormonal treatment has no beneficial effect on pregnancy rates
Exclude over-riding conditions (severe sperm dysfunction, blocked tubes etc)
If tubes patent, consider ovulation and intrauterine insemination
If diagnosed at laparoscopy - diathermy/laser improves fertility
If not pregnant after 6m - IVF
