5. Endometriosis Flashcards
Define: Endometriosis (2)
- the presence of endometrial tissue (glands and stroma) outside of the uterine cavity
- chronic condition, resolving only with menopause
Name ddx of endometriosis (4)
- Chronic PID, recurrent acute salpingitis
- Hemorrhagic corpus luteum
- Benign/malignant ovarian neoplasm
- Ectopic pregnancy
Name etiologies: Endometriosis (4)
- not fully understood; proposed mechanisms include (combination likely involved):
- retrograde menstruation (Sampson’s theory)
- immunologic: decreased NK cell activity limiting clearance of transplanted endometrial cells from pelvic cavity (may be due to decreased NK cell activity)
- metaplasia of coelomic epithelium
- extrapelvic disease may be due to aberrant vascular or lymphatic dissemination of cells
- e.g. ovarian endometriosis may be due to direct lymphatic flow from uterus to ovaries
Describe epidemiology: Endometriosis (3)
- incidence: 15-30% of pre-menopausal women
- mean age at presentation: 25-30 yr
- regresses after menopause
Name risk factors: Endometriosis (4)
- family history (7-10x increased risk if affected 1st degree relative)
- obstructive anomalies of the genital tract (earlier onset) – resolves with treatment of anomaly
- nulliparity
- age >25 yr
Name: Classic Triad of Endometriosis
- Dysmenorrhea
- Dyspareunia (cul-de-sac, uterosacral ligament)
- Dyschezia (uterosacral ligament, cul-de- sac, rectosigmoid attachment)
Name sites of occurence of endometriosis (5)
- ovaries: 60% patients have ovarian involvement
- broad ligament, vesicoperitoneal fold
- peritoneal surface of the cul-de-sac, uterosacral ligaments
- rectosigmoid colon, appendix
- rarely may occur in sites outside abdomen/pelvis, including lungs
Describe clinical features: Endometriosis (3)
- may be asymptomatic and can occur with one of 3 presentations
- pain
- infertility
- mass (endometrioma)
Describe pain in Endometriosis (7)
- menstrual symptoms
- cyclic symptoms due to growth and bleeding of ectopic endometrium, usually precede menses (24-48 h) and continue throughout and after flow
- secondary dysmenorrhea
- sacral backache with menses
- pain may eventually become chronic, worsening perimenstrually
- deep dyspareunia
- bowel and bladder symptoms
- frequency, dysuria, hematuria
- cyclic diarrhea/constipation, hematochezia, dyschezia (suggestive of deeply infiltrating disease)
Describe infertility in Endometriosis (2)
- 30-40% of patients with endometriosis will be infertile
- 15-30% of those who are infertile will have endometriosis
Describe mass in Endometriosis (4)
- ovarian mass can present with any of above symptoms or be asymptomatic
- physical examination:
- tender nodularity of uterine ligaments and cul-de-sac felt on rectovaginal exam
- fixed retroversion of uterus
- firm, fixed adnexal mass (endometrioma: an endometriotic cyst encompassing ovary)
Describe investigations: Endometriosis (2)
- definitive diagnosis can be made based on:
- direct visualization of lesions typical of endometriosis at laparoscopy
- biopsy and histologic exam of specimens (2 or more of: endometrial epithelium, glands, stroma, hemosiderin-laden macrophages)
- CA-125 (cancer antigen 125)
- may be elevated in patients with endometriosis but should NOT be used as a diagnostic test
Describe laparoscopy findings: Endometriosis (5)
- mulberry spots: dark blue or brownish-black implants on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
- endometrioma: “chocolate” cysts on the ovaries
- “powder-burn” lesions on the peritoneal surface
- early white lesions and clear blebs
- peritoneal “pockets”
Describe: SOGC guidelines for treatment of endometriosis (Figure)
True or false
surgical confirmation of endometriosis is required prior to starting medical management.
False
surgical confirmation of disease is NOT required prior to starting medical management.