Endometriosis - GM

Question 1

aetiology

Answer 1

has no single definitive cause
its is likely multifactorial, including genetic factors and retrograde menstruation

Question 2

age of onset

Answer 2

20-40 years
2-10% of all women
more commmon in white/asain ethnicities

Question 3

definition

Answer 3

endometrium-like tissue growing outside of the uterine cavity

Question 4

risk factors

Answer 4

early menarche (prolonged exposure to endogenous oestrogen)
short menstrual cycles
late menopause
delayed childbearing
nulliparity
family history
vaginal outflow obstruction
white ethnicity
low body mass index
autoimmune disease
smoking

Question 5

common locations of endometriotic implants

Answer 5

pelvic organs - ovaries, rectrouterine pouch, fallopian tubes, bladder, cervix
peritoneum
exprepelvic organs - eg. lung, diaphragm - less commonly affected

Question 6

pathophysiology

Answer 6

endometrial tissue reacts to the hormone cycle and proliferates under the influence of oestrogen
result in increase in inflmmatory and pain mediators
causes anatomical changes eg. adhesions
causes nerve dysfunction

Question 7

symptoms

Answer 7

chronic pelvic pain lasting six months or longer
dysmenorrhoea: pain often starting days before bleeding
deep dyspareunia
non gynae: dysuria, urgency, haematuria and dyschezia (painful bowel movements)
subfertility

Question 8

clinical examination

Answer 8

abdo palp: tenderness
pelvix exam: reduced organ mobility, tender nodularity in the posterior vaginal fornix, visible vaginal endometriotic lesions, rectrovaginal tenderness
normal pelvic or abdo examination does not exclude endometriosis

Question 9

differential diagnosis

Answer 9

PID
ectopic pregnancy
torsion of the ovarian cyst
appendicitis
irritable bowel syndrome
primary dysmennorrhea
uterine fibroids

Question 10

bedside/lab investigations

Answer 10

urine pregnancy tests (FBC, U&Es, CRP)
white cells may be raised in PID

Question 11

imaging

Answer 11

a transvaginal US may show endometriomas, however a norma scan does not exclude endometriomas
evidence of ovarian cysts or nodules in bladder or rectrovaginal septum

Question 12

diagnostic laparoscopy

Answer 12

gold standanrd investigation
invasive procedure

Question 13

macroscopic findings of andometrial tissue on ovaries

Answer 13

gunshot lesions or powder burn lesions: black, yellow-brown, or bluish nodules or cystsic structures seen on serosal surfaces of the ovaries and peritoneum
ovarian endometriomas or chocolate cysts: cyst-like structures that contain blood, fluid nd menstrual debris

Question 14

macroscopic findings on the fallopian tubes

Answer 14

salpingitis isthmica nodosa
nodular types changes resulting in increased risk of sterility/ectopic pregnancy and decreased transmittance

Question 15

initial management

Answer 15

NSAIDs/paracetamol
synthetric androgens
hormonal treatment (COCP or progesterone)
NSAIDs alone if pregnancy desired
GnRH agonists and estrogen-progestin OCPs for severe symptoms

symptoms may also improve after pregnancy as well as in menopause

Question 16

first line surgical management

Answer 16

excision or ablation of endometriosis, adhesiolysis and removal of endometriomas can be offered because this may improve chances of spontaneous pregnancy

Question 17

second line surgical therapy

Answer 17

if fertility is not a priority:
hysterectomy may be performed laparoscopically (with or without salpingo-oophorectomy)

Question 18

complications of endometriosis

Answer 18

infertility
endometriomas (cysts containing blood and endometriosis-like tissue) which may rupture or affect fertility
adhesions: secondary to endometriosis or surgery
bladder obstruction secondary to the adhesions
haematuria/rectal bleeding
anaemia
ectopic pregnancy - endometriosis in the uterotubal junctions inhibits implantation of the zygote

Question 19

adenomyosis (differential)

Answer 19

endomterial tissue in the myometrium due to hyperplasia of the endometrial basal layer