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Gynaecology > 7. Endometriosis and Adenomyosis > Flashcards

7. Endometriosis and Adenomyosis Flashcards

1
Q

What is endometriosis?

A

Endometriosis is the presence of tissue similar to the endometrium outside the uterine cavity. Diagnosis requires 2 of the following: endometrial glands, endometrial stroma, and haemosiderin pigment. Deeply infiltrating disease can affect organs like the vagina, bowel, bladder, or ureters.

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2
Q

What does the term “endometriosis” mean?

A

It’s the presence of endometrial-like tissue outside the uterine cavity.

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3
Q

What do we need to diagnose endometriosis?

A

2 of these 3 components: endometrial glands, endometrial stroma, and haemosiderin pigment.

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4
Q

Where can deeply infiltrating endometriosis affect?

A

It may affect the uterosacral ligaments, vagina, bowel, bladder, or ureters.

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5
Q

What causes endometriosis?

A

The cause is unknown, but there are several theories.

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6
Q

What is the Implantation Theory?

A

Retrograde menstruation may cause menstrual blood to flow into the pelvic cavity.

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7
Q

What happens after retrograde menstruation?

A

Endometrial fragments may implant and form deposits in the pelvic cavity.

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8
Q

Does this explain all cases of endometriosis?

A

No, not all women with retrograde menstruation develop endometriosis.

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9
Q

What is the Coelomic Metaplasia theory?

A

Coelomic cells may transform into Müllerian epithelium, leading to endometriosis.

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10
Q

How does this theory explain endometriosis in unusual places?

A

This theory may explain endometriosis in areas like the limbs, where these cells may have been isolated during fetal development

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11
Q

Can endometriosis spread through the lymphatic system?

A

Yes, endometrial tissue can be found in the lymphatic system.

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12
Q

Can endometriosis spread through the blood?

A

Yes, blood-borne spread can occur, which may explain deposits in organs like the lungs.

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13
Q

Is there a genetic link to endometriosis?

A

Yes, endometriosis is more common in close relatives.

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14
Q

What is the prevalence in close relatives?

A

6.9%, compared to 1% in the general population.

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15
Q

Do immune factors contribute to endometriosis?

A

Yes, immune responses may be impaired in women with endometriosis.

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16
Q

How does impaired immunity affect endometriosis?

A

It may allow endometrial tissue to implant and grow outside the uterus.

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17
Q

Are there other immune system changes

A

Increased inflammation and cytokines can promote implantation and growth of endometriotic tissue.

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18
Q

Can surgery contribute to endometriosis?

A

Yes, accidental transplantation of endometrial tissue during surgery can cause endometriosis.

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19
Q

What other menstrual factors increase risk?

A

Cryptomenorrhoea, frequent menses, and menorrhagia are associated with higher risk.

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20
Q

What other menstrual factors increase risk?

A

Cryptomenorrhoea, frequent menses, and menorrhagia are associated with higher risk.

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21
Q

Is endometriosis affected by hormones?

A

Yes, endometriotic tissue is hormone-sensitive.

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22
Q

What happens when there is no ovarian activity?

A

Endometriotic tissue may regress.

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23
Q

Does endometriotic tissue produce estrogen?

A

Yes, it has aromatase activity, converting androgens into estrogen locally.

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24
Q

Can endometriotic tissue cause pain?

A

Yes, it may contain nerve tissue, contributing to pain.

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25
Q

What is the prevalence of endometriosis in women of reproductive age?

A

Roughly 3-10% of women in the reproductive age group have endometriosis.

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26
Q

How common is endometriosis in infertile women?

A

The prevalence is higher in infertile women, ranging from 25-39%.

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27
Q

How does the prevalence of endometriosis compare to breast cancer?

A

More women are hospitalized each year for endometriosis than for breast cancer in the Western world.

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28
Q

What are the common sites of endometriosis?

A

Endometriosis can occur in various areas, including the ovaries, pelvic peritoneum, bowel, lower genital tract, urinary tract, and other sites.

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29
Q

Where is endometriosis most commonly found?

A

The ovaries are the most common site, with ovarian lesions found in 60-70% of patients.

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30
Q

Are ovarian lesions usually bilateral

A

Yes, ovarian lesions are bilateral in 50% of patients with endometriosis.

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31
Q

Where can pelvic peritoneal endometriosis occur?

A

It can occur on the peritoneum, Pouch of Douglas, utero-sacral ligaments, round ligaments, broad ligaments, and the surface of the uterus.

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32
Q

What complications can pelvic peritoneal endometriosis cause?

A

It can cause adhesions, obliterating the Pouch of Douglas and fixing the uterus in retroversion.

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33
Q

Is the bowel affected by endometriosis?

A

Yes, the bowel is commonly involved, especially the rectum and colon, usually affecting the serosa and muscularis layers.

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34
Q

Can bowel endometriosis affect the mucosa?

A

Bowel endometriosis rarely extends to the mucosa

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35
Q

Can endometriosis affect the cervix, vagina, or vulva?

A

Yes, endometriosis can affect the cervix, vagina, vulva, and even cause perineal deposits after episiotomy.

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36
Q

Can endometriosis affect the urinary tract?

A

Yes, endometriosis can affect the bladder and cause ureteric obstruction.

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37
Q

Can endometriosis occur in other areas besides the reproductive and urinary systems?

A

Yes, it can occur in scars (like Caesarean section scars), the umbilicus, and unusual sites like the inguinal region, limbs, lungs, and pleura.

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38
Q

Site of endometriosis

A
  1. Ovary
  2. Pelvic peritoneal endometriosis deposits
  3. Bowel endometriosis
  4. Lower genital tract
  5. Urinary tract
  6. Other sites
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39
Q

How does the symptomatology of endometriosis vary?

A

Symptoms depend on the severity of the disease, local reactions, and the site of the deposits.

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40
Q

Can extensive endometriosis be symptom-free?

A

Yes, extensive disease may have few or no symptoms, while small deposits can cause significant discomfort.

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41
Q

What is a common symptom of endometriosis related to menstruation?

A

Dysmenorrhoea, or painful periods, is present in over 50% of patients.

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42
Q

What types of dyspareunia are common in endometriosis?

A

Deep dyspareunia (pain during intercourse) and positional pain are common.

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43
Q

How common is pelvic pain in women with endometriosis?

A

About 12.5% of women with pelvic pain have endometriosis, and up to one-third of women with chronic pain will be diagnosed with it.

44
Q

How does endometriosis affect fertility?

A

Endometriosis is a common cause of involuntary infertility. It should be suspected in any woman with infertility.

45
Q

What menstrual issues are associated with endometriosis?

A

Premenstrual spotting, menorrhagia (heavy bleeding), short cycles, and ovulatory dysfunction are common.

46
Q

Can endometriosis affect the urinary tract?

A

Yes, if the bladder is involved, cyclical haematuria (blood in the urine) may occur.

47
Q

How can endometriosis affect the bowel?

A

Bowel involvement can mimic the symptoms of carcinoma, especially if the bowel is significantly affected.

48
Q

At what age does endometriosis typically present?

A

It can present shortly after menarche (first menstruation) in young women and may also be seen in post-menopausal women if hormone replacement therapy (HRT) reactivates the disease

49
Q

Does pregnancy have any effect on endometriosis?

A

Yes, pregnancy may have a protective effect, reducing symptoms.

50
Q

How does the contraceptive pill affect endometriosis?

A

The contraceptive pill can also have a protective effect and reduce symptoms.

51
Q

Does endometriosis affect certain ethnic groups more?

A

No, endometriosis occurs in all ethnic groups.

52
Q

What are common physical findings in endometriosis?

A

The uterus may be fixed and retroverted, and ovaries can be enlarged if affected.

53
Q

What findings might suggest endometriosis in the ligaments and septum?

A

Thickened and tender utero-sacral ligaments, and nodularity in the recto-vaginal septum, especially if there’s dyspareunia (pain during intercourse).

54
Q

Are there any specific findings during a vaginal examination?

A

Bluish lesions on the vulva, vagina, or cervix, and ill-defined tubo-ovarian masses may be found.

55
Q

When is the best time to detect nodules?

A

Nodules are best detected during menstruation.

56
Q

Can symptoms and examination alone confirm endometriosis?

A

No, diagnosis can’t be made with certainty based only on symptoms and examination.

57
Q

How useful is ultrasound in diagnosing endometriosis?

A

Ultrasound can be useful for detecting endometriomas and deeply infiltrating disease but is not effective for visualizing peritoneal disease.

58
Q

What is the gold standard for diagnosing endometriosis?

A

Laparoscopy is the gold standard, allowing visualisation, staging, and histological diagnosis.

59
Q

What classification system is used to stage endometriosis during laparoscopy?

A

The American Society of Reproductive Medicine staging system is currently used.

60
Q

Can negative histology exclude the diagnosis?

A

No, negative histology does not exclude the diagnosis if there is visual confirmation of disease.

61
Q

Does the extent of endometriosis always correlate with the symptoms?

A

No, some women with severe disease experience minimal pain, while those with mild disease may experience severe pain.

62
Q

Can treatment begin without a laparoscopy?

A

Yes, treatment can be started empirically without the need for laparoscopy.

63
Q

Are there any new methods being researched to diagnose endometriosis?

A

Yes, research into genomics and proteomics is ongoing to improve diagnostic methods.

64
Q

What are the two main types of treatment for endometriosis?

A

Treatment can be medical or surgical.

65
Q

Does hormonal manipulation cure endometriosis?

A

No, hormonal manipulation doesn’t affect the primary cause of endometriosis and may not always provide complete pain relief.

66
Q

What happens when medication is stopped?

A

Symptom recurrence is common after discontinuing medication.

67
Q

Are all treatments equally effective?

A

Yes, but they vary in side effects and cost.

68
Q

What is the goal of treatment with the oral contraceptive pill for endometriosis?

A

The goal is to create a “pseudopregnancy” state.

69
Q

What are the common side effects of the oral contraceptive pill in endometriosis treatment?

A

Nausea, vomiting, weight gain, and breakthrough bleeding.

70
Q

Does the oral contraceptive pill affect fertility?

A

Yes, the patient is infertile while using this therapy.

71
Q

How are progestogens used in treating endometriosis?

A

Progestogens can be used alone or in preparation for surgery. They are effective in suppressing endometriotic deposits but are not always successful in symptom control.

72
Q

What are some examples of progestogen treatments for endometriosis?

A

Depo Provera 150-300 mg every 3 months
Dydrogesterone 10 mg daily
Norethisterone 5-15 mg daily
Oral Provera 10-30 mg daily

73
Q

What is the purpose of these progestogen treatments?

A

They aim to cause endometrial atrophy and, in turn, atrophy of ectopic deposits.

74
Q

What is Dienogest, and how does it work for endometriosis?

A

Dienogest is an oral progestin that relieves endometriosis-related pain by causing decidualisation and eventual atrophy of the endometrium. It has anti-proliferative, anti-inflammatory, and anti-angiogenic effects.

75
Q

Which strength of Dienogest has been shown to be most effective?

A

The 2 mg strength has proven to be the most effective in studies.

76
Q

What is the Mirena IUD used for in endometriosis treatment?

A

It’s used for mild to moderate endometriosis. Pain relief can last up to 3 years, after which a new device is needed.

77
Q

How does Gestrinone help with endometriosis?

A

Gestrinone, a progestogen, suppresses endometriotic deposits and provides symptomatic relief.

78
Q

What are the side effects of Gestrinone?

A

It may cause androgenic side effects, but typically less than Danazol.

79
Q

How do GnRH analogues work in treating endometriosis?

A

They desensitize the pituitary, reducing FSH and LH levels, causing a medical “gonadectomy.”

80
Q

What are the side effects of GnRH analogues?

A

Side effects mimic ovarian failure, including hot flushes and menopausal symptoms. These are reversible once treatment stops.

81
Q

How long is GnRH analogue treatment usually given?

A

Treatment is typically limited to 6 months due to potential bone loss and lipid changes.

82
Q

Can GnRH analogues be combined with other treatments?

A

Yes, combining them with a small dose of estrogen for bone protection has proven successful.

83
Q

What is Danazol, and how does it treat endometriosis?

A

Danazol is an androgen derivative that inhibits steroidogenesis, suppressing estrogen levels and causing remission of the disease.

84
Q

What are the common side effects of Danazol?

A

Side effects include weight gain, acne, hirsutism, voice changes, and hot flushes. About 85% of patients experience side effects.

85
Q

Why is careful monitoring necessary with Danazol?

A

Some side effects, like voice changes, are irreversible, so close monitoring is essential.

86
Q

What is Danazol?

A

Danazol is an impeded androgen derived from 17-alpha ethinyl testosterone.

87
Q

What is the typical dosage and duration of Danazol treatment?

A

The usual dose is up to 800 mg daily for 3 to 6 months.

88
Q

How does Danazol work in the body?

A

Danazol prevents the mid-cycle LH surge, binds to steroid receptors, and inhibits enzyme activity, which results in a reduction of steroidogenesis.

89
Q

What are some common side effects of Danazol?

A

Common side effects include weight gain, acne, hirsutism, voice changes, and hot flushes. About 85% of patients on an adequate dose experience side effects.

90
Q

What benefits can Danazol offer in terms of disease management?

A

Danazol is effective at suppressing estrogen levels and can lead to complete remission of certain diseases.

91
Q

Write the medical treatment options for endometriosis

A
  1. Oestrogen and gestogen treatment
  2. Progestogens alone
  3. Mirena intrauterine system
  4. Gestrinone
  5. GnRH analogues
  6. Danazol
92
Q

How does the severity of symptoms and the site of endometriosis affect surgical treatment?

A

Surgical treatment depends on the severity of symptoms, the location of endometriosis, and the patient’s fertility wishes. Severe cases, such as large endometriomas or adhesive disease, typically require surgery.

93
Q

What is the aim of conservative surgery for endometriosis?

A

The goal of conservative surgery is to divide adhesions, mobilize the adnexa, and remove endometriomata to improve symptoms and fertility.

94
Q

What is the treatment for deeply infiltrating endometriosis?

A

Deeply infiltrating endometriosis requires surgery to remove the lesions.

95
Q

How should endometriomas be treated surgically?

A

Endometriomas should be drained and the wall of the pseudocapsule should be stripped or cauterized. Simple incision and drainage leads to recurrence. Stripping the wall has been shown to delay pain and disease recurrence.

96
Q

What is the effectiveness of stripping and cauterization of peritoneal endometriosis?

A

Stripping and cauterizing peritoneal endometriosis with a laser is superior to diagnostic laparoscopy in terms of treating the condition.

97
Q

Why do some women fail to respond to surgical intervention for endometriosis?

A

Failure to respond can occur due to inadequate excision of lesions, recurrence of lesions, or if the pain is not due to endometriosis.

98
Q

What role does laparoscopic uterosacral nerve ablation play in treating endometriosis?

A

Laparoscopic uterosacral nerve ablation alone does not alleviate dysmenorrhoea associated with endometriosis.

99
Q

When is radical surgery necessary for endometriosis?

A

Radical surgery may be needed in cases where the symptoms are severe and the disease is widespread, often requiring pelvic clearance or bowel resection.

100
Q

What hormone therapy is recommended for young patients after radical surgery, such as bilateral oophorectomy?

A

Hormone therapy is required after radical surgery to prevent symptoms of menopause. The benefits of hormone therapy generally outweigh the risks of disease recurrence, although the ideal regimen is still unclear.

101
Q

Is hormone therapy necessary after hysterectomy for endometriosis?

A

Adding a progestogen after a hysterectomy is unnecessary but may protect against the unopposed action of estrogen on residual disease. However, this should be balanced against the increased risk of breast cancer associated with combined hormone therapy.

102
Q

When might both medical and surgical therapies be used for endometriosis?

A

In many cases, both medical and surgical therapies are used. Medical therapy is typically given for 3-6 months to reduce the disease, after which surgery is considered

103
Q

How does endometriosis affect fertility?

A

Infertility can occur in both mild and severe endometriosis. In severe cases, pelvic anatomy distortion may lead to infertility due to tubal factors. Mild endometriosis may affect fertility through other mechanisms like abnormal oocyte quality or implantation issues.

104
Q

Why is infertility more difficult to explain in mild endometriosis?

A

In mild endometriosis, infertility can be harder to explain, especially if tubal patency is intact. Possible causes include defective ovulation (LUF syndrome), abnormalities with implantation due to ectopic endometrium, impaired sperm function, and abnormal prostaglandin production affecting ovarian function and tubal motility.

105
Q

What treatment is recommended for women with minimal to moderate endometriosis and tubal patency?

A

Women with minimal to moderate endometriosis who have tubal patency are often offered artificial insemination as a treatment for infertility.

106
Q

What is the main challenge in treating young women with severe endometriosis?

A

One of the most difficult clinical challenges is managing severe endometriosis in very young women who wish to preserve their future fertility. Careful consideration of treatment options is essential for both short- and long-term management.

107
Q

Why is careful investigation and discussion important in managing endometriosis?

A

Endometriosis is common and can be debilitating, so it’s important to thoroughly investigate the condition and discuss treatment options with patients to ensure both immediate and long-term care needs are met.

Gynaecology (27 decks)

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