2.7 Endometriosis

Question 1

What is endometriosis?

Answer 1

ectopic endometrial tissue outside the uterus, a lump is an endometrioma

Question 2

What is a chocolate cyst?

Answer 2

endometrial tissue in the ovary

Question 3

What is adenomyosis?

Answer 3

endometrial tissue within the myometrium of the uterus

Question 4

Four theories for the physiology of how endometriosis occurs?

Answer 4

• RETROGRADE menstruation up the Fallopian tubes
• embryonic cells destined to be endometrial tissue remained outside the uterus during development
• endometrial cells spread via lymphatics
• cells outside uterus undergo metaplasia into endometrial cells

Question 5

Main symptom of endometriosis is pelvic pain, how does it cause pain?

Answer 5

responds to hormones in the same way so during menstruation the ectopic tissue sheds its lining and bleeds
blood irritates and inflames tissue near sites of endometriosis giving “cyclical, dull, heavy or burning pain with menstruation”

(in bowel or bladder can lead to blood in urine or stools)

Question 6

What aspect of endometriosis might lead to a chronic, NON-cyclical pain that can be sharp or stabbing ± nausea?

Answer 6

this can be caused by adhesions

they form due to the localised bleeding and inflammation leading to scar tissues. Or from abdo surgery.

Question 7

Why might endometriosis reduce fertility?

Answer 7

Unclear. Could be:

• tissue in tubes
• kinking of tubes
• in ovaries and affecting ovulation

Question 8

Presentation of endometriosis?

Answer 8

• cyclical abdo or pelvic pain
• deep dypareunia
• dysmenorrhoea
• infertility
• cyclical bleed from other sites (eg haematuria)

cyclical:

• urinary Sx
• bowel Sx

Question 9

What might you find on examination when suspecting endometriosis?

Answer 9

• endometrial tissue visible on vagina, esp posterior fornix
• fixed cervix on bimanual exam
• tenderness of vagina, cervix and adnexa

Question 10

How is endometriosis diagnosis?

Answer 10

Laparoscopy is gold standard, biopsy can give confirmation. Also allows surgeon to remove deposits.

US scan may show chocolate cysts but are often unremarkable.

Question 11

Staging endometriosis?

Answer 11

NICE recommend detailed description rather than a staging system.
American Society of Repro Medicine has staging system:
1 - small superficial
2 - mild but deeper
3 - deeper, ovaries and mild adhesions
4 - deep and large, affecting ovaries and extensive adhesions

Question 12

What hormonal management can be tried before laparoscopy?

Answer 12

• COCP
• POP
• depoprovera injection
• nexplanon inplant
• mirena coil
  (stop ovulation and reduce endometrial thickening)
• GnRH agonists (induce menopause)

Question 13

Surgical options for endometriosis?

Answer 13

• laparoscopic (excise / ablate and adhesiolysis)

- hysterectomy