Definition endometriosis
Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. While some women with endometriosis can experience painful symptoms and/or infertility, others have no symptoms at all.
Prevalence of endometriosis
The exact prevalence of endometriosis is unknown but estimates range from 2 to 10% of women of reproductive age, to 50% of infertile women.
Symptoms of endo
- In the presence of gynaecological symptoms such as: dysmenorrhoea, non-cyclical pelvic pain, deep dyspareunia, infertility and fatigue in the presence of any of the above.
- In women of reproductive age with non-gynaecological cyclical symptoms (dyschezia, dysuria, haematuria and rectal bleeding, shoulder pain)
Clinical examination findings
- (painful) induration and/or nodules of the rectovaginal wall found during clinical examination or visible vaginal nodules in the posterior vaginal fornix.
- Consider the diagnosis of ovarian endometrioma in women with adnexal masses detected during clinical examination
- Clinicians may consider the diagnosis of endometriosis in women suspected of the disease even if the clinical examination is normal
Diagnosing endometriosis:
The diagnosis of endometriosis is suspected based on the history, the symptoms and signs, is corroborated by physical examination and imaging techniques and is finally proven by histological examination of specimens collected during laparoscopy. It is not necessary to diagnose endometriosis surgically and it is appropriate to see if symptoms improve with hormonal medication.
The GDG recommends that clinicians: GPP perform a laparoscopy to diagnose endometriosis, although evidence is lacking that a positive laparoscopy ‘without histology’ proves the presence of disease. confirm a positive laparoscopy by histology, since positive histology confirms the diagnosis of endometriosis even though negative histology does not exclude it. The GDG recommends that clinicians obtain tissue for histology in women undergoing surgery for ovarian endometrioma and/or deep infiltrating disease, to exclude rare instances of malignancy.
Imaging for endo
- USS: Useful for identifying endometriomas, if operator experienced may identify rectal endometriosis. Features of endometriosis: ground glass echogenicity and one to four compartments and no papillary structures with detectable blood flow.
- MRI to identify further endometriosis/extent of disease
Treatment for endo
- Hormone based contraceptives – limited evidence for combined hormonal vs progestogen.
- Analgesia – limited evidence. Try NSAIDs.
- Aromatase inhibitors may work for women with rectovaginal endometriosis in addition to hormonal medication
- Consider laparoscopy if ongoing symptoms despite hormonal treatment. Altough waiting for effect of hormonal contraception may result in a delay in diagnosis and deep infiltrative disease later in life.
- Laparoscopy- excise lesions and send for histology. May improve pain symptoms. If endometrioma- aim for cystectomy rather than drainage. Surgical removal of deep endo should be done by a specialist and is associated with higher complication rates.
- Consider hysterectomy with removal of the ovaries and all visible endometriosis lesions in women who have completed their family and failed to respond to more conservative treatments. Women should be informed that hysterectomy will not necessarily cure the symptoms or the disease
Fertility and endo
- No evidence of benefit in using medical treatment e.g. GnRH analogues
- In women with minimal to mild endometriosis, the evidence, summarised in a Cochrane review, shows that operative laparoscopy is more effective than diagnostic laparoscopy in improving ongoing pregnancy rates.
- In women with ovarian endometrioma receiving surgery for infertility or pain, excision of endometrioma capsule increases the spontaneous post-operative pregnancy rate when compared with drainage and electrocoagulation of the endometrioma wall
- In women with moderate to severe endometriosis, there are no controlled studies comparing reproductive outcome after surgery and after expectant management.
- For infertile women with deep endometriosis, we found no evidence to recommend performing surgical excision of deep nodular lesions prior to ART to improve reproductive outcomes (Bianchi et al., 2009; Papaleo 8 Dunselman et al. by guest on January 13, 2016 http://humrep.oxfordjournals.org/ Downloaded from et al., 2011). However, these women often suffer from pain, requesting surgical treatment.
A 26 year old nulliparous woman with pelvic pain unresponsive to simple analgesia and primary infertility presents for review. She has been told by her GP that endometriosis is the likely cause.
a. With respect to this woman’s pain:
i) List four pain symptoms most commonly associated with endometriosis. (4 marks)
ii) Give one characteristic feature from both her history and her physical examination that supports each pain symptom. (4 marks)
Answer in a table with 3 columns headed: Pain symptom, History, and Examination. Do not use the same history or examination characteristic more than once (although such characteristics may be appropriate for more than one pain symptom).
Symptom History Examination
Dysmenorrhoea Painful periods Tenderness on bimanual examination e.g. uterosacral ligaments
Dyspareunia Pain with deep penetration during intercourse Adnexal mass (endometrioma), fixed retroverted uterus
Dysuria Pain with micturition Suprapubic tenderness on abdominal examination
Dyschesia Pain with opening bowels Nodules palpable in Pouch of Douglas
If endometriosis is confirmed, in general terms what are the goals of management for this woman? (2 marks)
To improve quality of life from reduction in pain, and to treat infertility.
What are the principles of the surgical management of endometriosis? (5 marks)
Aims:
• Remove macroscopic endometriotic deposits
• Restore normal pelvic anatomy
• Prevent future adhesions
• Minimise complications - pelvic organ damage, haemorrhage
• Retain fertility
Preop:
• Appropriate counseling and consent
• MDT input and planning eg combination case with general surgeons with deeply invasive disease, may require additional investigations eg MRI
Approach: Laparoscopy preferred over laparotomy
• Decreased tissue damage
• Increased magnification
• Faster recovery
Technique:
• Removal of all macroscopic disease as is safe to do so
• Peritoneal deposits – excision preferred over ablation
• Endometriomas – excision preferred over drainage
• Release adhesions and reduce risk of future adhesions, and restore normal anatomy
• Preserve fertility – avoid damage to tubes and minimise damage to ovaries
• Avoid damage to surrounding structures – bladder, bowel, ureters
a. Briefly describe 4 theories for the pathogenesis of endometriosis (4 marks)
- Implantation theory – retrograde menstruation causes deposits of endometrial glands and stroma in the pelvis. An abnormal/excessive inflammatory response to these deposits occurs.
- Coelomic metaplasia theory – cells of the peritoneum may have pleuripotency and undergo metaplasia to form endometrial cells.
- Mullerianosis – during embryogenesis, as the Mullerian tracts descend they leave behind some endometrial cells.
- Dissemination theory – endometrial cells are transported via blood/lymphatics.
b. Outline how endometriosis may cause subfertility (2 marks)
- Inflammatory products cause direct toxicity to oocyte/sperm/embryo
- Endometriomas destroy normal ovarian tissue and function
- Adhesions cause decreased tubal motility and function, impair oocyte release, and block sperm entry into cavity
- Decreased frequency of intercourse 2’ dyspareunia
A 24 year-old woman presents with a 2 year history of primary infertility and severe dysmenorrhoea, deep dyspareunia and dyschezia. A recent diagnostic laparoscopy showed small deposits of endometriosis in the Pouch of Douglas, the left uterosacral ligament and bladder. Hormone profiles show no abnormality and normal ovulation, her partner’s semen analysis is normal.
d. Describe each of the management steps you would recommend for this woman for her fertility and pain, identifying the level or type of evidence that supports each step (6 marks)
Pain
• Medical:
o Evidence of benefit for COCP, progesterone (Level I) however will prevent pregnancy
o Evidence of benefit for GnRHa (Level II), however will prevent pregnancy
o No evidence for exercise, NSAIDs, paracetamol, complimentary therapies (Level I, Cochrane reviews)
• Surgical:
o Should be reserved for women with endometriosis related pain in whom medical treatment has failed (Level IV) or is not suitable (eg desire for pregnancy)
o Evidence of benefit for laparoscopic management of endometriosis (Level II), and is preferred over laparotomy
o Insufficient evidence whether superficial endometriotic lesions should be excised or ablated in the treatment of pain. No difference in outcome illustrated in a small RCT (Level II)
o Surgical treatment of deeply infiltrating endometriosis likely to be of greater benefit in terms of pain relief than excision of superficial disease (Level IV)
o Surgical treatment of deeply infiltrating endometriosis may require particular experience with a multidisciplinary approach (Level IV)
Fertility
• Medical:
o No evidence of benefit for any medical therapies (Level I)
• ART:
o IUI or controlled simulation alone – no benefit (Level I)
o IUI and controlled stimulation together can be offered as this increase live birth rates (Level II evidence)
o IVF – success rates are slightly in patients with endometriosis than with other diagnoses (Level III). GnRHa use prior to an IVF cycle improves pregnancy rates for women with endometriosis (Level II)
• Surgical:
o Laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality (Level I)
o The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial (Level III)
o Cystectomy of endometrioma >3cm prior to ART does not improve pregnancy rates (Level I)
What are the factors in a woman which would have implications for treatment options
in endometriosis?
Degree of pain and impact on life Desire for fertility Age Medical comorbidities Previous treatment options tried and outcomes Extent of disease Surgical history
What are the medical treatments of endometriosis and their advantages?
Hormonal:
o COCP first line – gives significant relief from dysmenorrhea, also provides
contraception, reversible effects
o Progestogens – oral, depot, Mirena (LNG-releasting IUS) – effective in relief of
dysmenorrhea, depot given 3 monthly which improves compliance over daily
pill, Mirena lasts for 5 years which improves compliance and has lower systemic
progestogen side effects
o GnRHa - useful if do not respond to above, with add back therapy, provides
amenorrhoea in most, can give as monthly or 3 monthly implants
o Danazol – effective in decreasing pain, provides amenorrhoea (but many side
effects), used infrequently.
Non hormonal:
o NSAIDs – decreases dysmenorrhea, useful as adjunct during 1 st cycle until
hormonal treatment takes effect, does not prevent pregnancy if desires
conception
Describe the surgical treatments for endometriosis
Fertility sparing surgical treatments: (laparoscopic approach preferred)
o Ablation of peritoneal deposits
o Excision of peritoneal deposits (benefit of histological diagnosis, no evidence to
suggest reduced recurrence over ablation therapy)
o Excision of endometrioma (preferred over drainage, lower recurrence rates)
o Treatment of deeply invasive endometriosis, may require bowel surgeon for
shaving, bowel resection
Definitive surgery:
o Hysterectomy + BSO – provides “cure” but may not be appropriate in young
women. Need to have completed family and be counseled on risks of surgical
menopause
