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Practice bulletins > #114 Management of Endometriosis > Flashcards

#114 Management of Endometriosis Flashcards

1
Q

What percentage of reproductive age women have endometriosis?

A

6-10%

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2
Q

What is the prevalence of endometriosis in infertile women?

A

38% (range, 20-50%)

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3
Q

What is the prevalence of endometriosis in women with chronic pelvic pain?

A

71-87%

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4
Q

Which race is more predisposed to endometriosis?

A

All equal

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5
Q

Is there a familial connection with endometriosis?

A

Patient with first-degree relative affected have a nearly 7-10 fold increase in developing endometriosis

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6
Q

What is the proposed inheritance of endometriosis?

A

Polygenic-multifactorial mechanism

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7
Q

What are the primary manifestations of endomestriosis?

A

Chronic pain and infertility. Dysmenorrhea, menorrhagia, dyspareunia

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8
Q

What is the principal suspected pathogenesis of endometriosis?

A

Attachment and implantation of endometrial glands and stroma on the peritoneum from retrograde menstruation. Other theories include hematogenous or lymphatic transport, stem cells from bone marrow, and coelomic metaplasia

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9
Q

What hormones/chemicals/enzymes are involved in the development of endometriosis?

A

Local overproduction of prostaglandins by an increase in COX-2 activity and overproduction of local estrogen by increased aromatase activity. Progesterone resistance amplifies the local estrogenic effect

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10
Q

What inflammatory cytokines are most commonly found with endometriosis?

A

Tumor necrosis factor alpha and interleukins 1, 6, 8

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11
Q

Is nerve growth factor associated with the pain of endometriosis?

A

Yes. Highly expressed in endometriotic lesions, especially rectovaginal lesions

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12
Q

Is the innervation of the uterus changed in endometriosis?

A

It can be. Changes have been reported in patients with endometriosis and may explain the severe dysmenorrhea and improvement in symptoms from hysterectomy

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13
Q

Specifically, how does endometriosis affect fertility (mechanism)?

A

Sperm function may be affected oxidative stress and inflammatory cytokines. Environment can cause abnormalities in oocyte cytoskeleton function. AMH is decreased in early endometriosis. Advanced endometriosis with adhesions > anatomic abnormalities

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14
Q

How does endometriosis affect AMH?

A

decreases it

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15
Q

What are risk factors for endometriosis?

A

Early menarche (<11yo), shorter cycles (<27 days), heavy/prolonged cycles

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16
Q

What decreases the risk of endometriosis?

A

Higher parity and increased duration of lactation. Regular exercise (>4h per week)

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17
Q

How is the pelvic pain of endometriosis characteristically described?

A

Secondary dysmenorrhea, deep dyspareunia, sacral backache during menses

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18
Q

In what ways can endometriosis affect bowel movements?

A

Perimenstrual tenesmus, diarrhea, constipation, cramping and dyschezia

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19
Q

In what ways can endometriosis affect the urinary system?

A

Dysuria and hematuria

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20
Q

Does the stage of endometriosis correlate with symptoms?

A

Not necesarily

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21
Q

What has been associated with severity of pain with endometriosis?

A

Depth of infiltration of endometriotic lesions

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22
Q

What is the most predictable symptoms of deeply infiltrating endometriosis?

A

Painful defecation during menses and severe dyspareunia

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23
Q

How can you make a definitive diagnosis of endometriosis?

A

Histology of lesions removed at surgery

24
Q

What is the histologic appearance of endometriosis?

A

Endometrial glands and stroma with vary amounts of inflammation and fibrosis

25
Q

What are the possible visual appearances of endometriosis lesions?

A

Black powder-burn lesions, red or white lesions.

26
Q

Is there a role for MRI in cases of suspected endometriosis?

A

Can be used for equivocal ultrasound results in cases of rectovaginal or bladder endometriosis

27
Q

What is the role of transvaginal ultrasound in endometriosis?

A

Can be used to identify endometriomas. Also imaging of choice to detect the presence of deeply infiltrating endometriosis of the rectum or rectovaginal septum

28
Q

Which society devised the most commonly used classification system for endometriosis

A

American Society for Reproductive Medicine

29
Q

What does the stage of endometriosis correlate to?

A

The operative findings - uniform way of comparing results of various therapies. Does not correlate to fertility outcomes, pain, dyspareunia, infertility.

30
Q

Does surgical management increase pregnancy rates in endometrisos?

A

Yes.

31
Q

If performing surgery for fertility, is it better to drain and ablate the cysts wall of an endometrioma or remove it entirely?

A

Better to remove it entirely. Pregnancy rates of 60.9% for excision vs 23.4% with drainage and ablation

32
Q

What medications can be used to reduce pain in endometriosis?

A

Progestins, danazol (androgenic drug), COCs, NSAIDs, and GnRH agonists

33
Q

What should you do if your initially therapy fails in patients with suspected endometriosis?

A

Can either offer diagnostic laparoscopy to confirm dx or empiric treatment with another suppressive medication

34
Q

What type of medication is danazol?

A

Androgenic drug

35
Q

What is the side effect profile of danazol?

A

Acne, hirsutism, myalgias

36
Q

What are the side effects of GnRH agonists?

A

Hot flushes, vaginal dryness, osteopenia

37
Q

How long can a patient use a GnRH agonist?

A

Up to 1 year with add-back therapy.

38
Q

What is the point of add-back therapy with GnRH therapy?

A

Reduces or eliminates bone mineral loss and provides symptomatic relief

39
Q

What are options for add-back therapy?

A

progestins alone, progestins and bisphosphonates, low-dose progestins, and estrogens

40
Q

What else should patients take when they are taking GnRH agonist with add-back therapy?

A

Daily calcium supplements (1,000mg)

41
Q

What is the chance of requiring further surgery after surgical removal of endometriosis?

A

36%

42
Q

Does presacral neurectomy have an effect on endometriosis?

A

Decreases midline pain

43
Q

What are potential postoperative side effects of presacral neurectomy?

A

Constipation and urinary dysfunction

44
Q

At what size should an endometrioma be removed?

A

Some societies recommend removal if the cyst is more than 3cm

45
Q

Should a woman with no diagnosis of endometriosis have a suspected endometrioma removed?

A

Yes, in order to obtain histologic confirmation that the cyst is benign

46
Q

Should preoperative medical suppression therapy be used for endometriosis surgery?

A

No data to support this use

47
Q

Is there a role for postoperative medical therapy after endometriosis surgery?

A

Yes, multiple medical options (GnRH agonist, COCs, LNG IUD) with prolonged reduced dysmenorrhea

48
Q

What is first line therapy for extrapelvic endometriosis, pain management (apart from ureter or bowel obstruction)?

A

GnRH agonist. Surgery is best for obstruction of ureter or bowel

49
Q

What is the likelihood of recurrent endometriosis symptoms after hysterectomy with ovarian conservation?

A

62%

50
Q

What is the likelihood of needing additional surgical treatment after having hysterectomy with ovarian sparing for endometriosis?

A

31%

51
Q

What is the recurrence rate of endometriosis after hysterectomy with BSO?

A

10%

52
Q

What is the likelihood of needing additional surgery for endometriosis after hysterectomy with BSO?

A

4%

53
Q

Is estrogen contraindicated after definitive surgery for endometriosis (TLH BSO)?

A

No.

54
Q

Where is the most common site of endometriosis recurrence after TLH BSO?

A

Large and small bowel (likely persistent rather than recurrent disease)

55
Q

Is there a role for hormone therapy after definitive surgery for endometriosis-associated pain?

A

Limited data. Appears to be no advantage after TLH BSO

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