Chronic Pelvic Pain Flashcards
What is endometriosis?
Endometriosis is a chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity
What sites are most commonly affected by endometriosis?
Commonly the pelvic cavity (including the ovaries), the uterosacral ligaments, the pouch of Douglas, the rectosigmoid colon, and the bladder and distal ureter.
Other sites are rarely involved but include the umbilicus, scar sites (eg, following caesarean section and laparoscopy), the pleura and pericardium, and the central nervous system.
What is adenomyosis?
Adenomyosis is the invasion of the myometrium by endometrial tissue.
How many people are affected by endometriosis?
Endometriosis is estimated to affect 10-15% of women of reproductive age.
Risk factors for endometriosis:
- An early menarche, late menopause, delayed childbearing, short menstrual cycles or long duration of menstrual flow.
- Obstruction to vaginal outflow eg, hydrocolpos, female genital mutilation or defects in the uterus or Fallopian tubes.
- Genetic factors: Risk for first-degree relatives of women with severe endometriosis is six times higher than that for relatives of unaffected women.
What factors are protective for endometriosis?
multiparty and the use of oral contraceptives.
Symptoms of endometriosis:
- Dysmenorrhoea.
- Dyspareunia.
- Cyclical or chronic pelvic pain.
- Subfertility.
Other symptoms may include bloating, lethargy, constipation and low back pain. Less common symptoms include cyclical rectal bleeding, dysuria, abdominal pain, painful defecation, menorrhagia, diarrhoea, haematuria, menstrual irregularity, and cyclical pain or bleeding (eg, epistaxis, haemoptysis) at extrapelvic sites.
The clinical presentation is variable, with some women experiencing several severe symptoms and others having no symptoms at all. The severity of symptoms tends to increase with age. Women with endometriosis may have no symptoms and be diagnosed incidentally or during investigations for infertility.
Suspect endometriosis in women (including young women aged 17 and under) presenting with 1 or more of the following symptoms or signs:
- chronic pelvic pain (lasting for 6 months or longer)
- period-related pain (dysmenorrhoea) affecting daily activities and quality of life
- deep pain during or after sexual intercourse
- period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements
- period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine
- infertility in association with 1 or more of the above.
Signs of endometriosis:
-Examination is often normal.
However, there may be:
- Posterior fornix or adnexal tenderness.
- Palpable nodules in the posterior fornix or adnexal -masses (endometriosis can cause cystic lesions on the ovaries, known as ‘chocolate cysts’).
- Bluish haemorrhagic nodules visible in the posterior fornix.
What can be a useful diagnostic tool that patients can do for themselves?
-inform women with suspected or confirmed endometriosis that keeping a pain and symptom diary can aid discussions.
What is the diagnostic use of CA125 in ?endometriosis?
Do not use serum CA125 to diagnose endometriosis.
If a coincidentally reported serum CA125 level is available, be aware that:
-a raised serum CA125 (that is, 35 IU/ml or more) may be consistent with having endometriosis
-endometriosis may be present despite a normal serum CA125 (less than 35 IU/ml).
What is the first line investigation for ?endometriosis?
Transvaginal USS
When can MRI be appropriate in ?endometriosis?
Do not use pelvic MRI as the primary investigation to diagnose endometriosis in women with symptoms or signs suggestive of endometriosis.
Consider pelvic MRI to assess the extent of deep endometriosis involving the bowel, bladder or ureter.
What is the diagnostic gold standard for endometriosis?
Consider laparoscopy to diagnose endometriosis in women with suspected endometriosis, even if the ultrasound was normal.
For women with suspected deep endometriosis involving the bowel, bladder or ureter, consider a pelvic ultrasound or MRI before an operative laparoscopy.
During a diagnostic laparoscopy, consider taking a biopsy of suspected endometriosis:
- to confirm the diagnosis of endometriosis (be aware that a negative histological result does not exclude endometriosis)
- to exclude malignancy if an endometrioma is treated but not excised.
If a full, systematic laparoscopy is performed and is normal, explain to the woman that she does not have endometriosis, and offer alternative management.
When to refer endometriosis?
Do not exclude the possibility of endometriosis if the abdominal or pelvic examination, ultrasound or MRI are normal. If clinical suspicion remains or symptoms persist, consider referral for further assessment and investigation.
Consider referring women to gynaecology for an ultrasound or opinion if:
- they have severe, persistent or recurrent symptoms of endometriosis
- they have pelvic signs of endometriosis OR
- initial management is not effective, not tolerated or contraindicated.
Refer women to a specialist endometriosis service if they have suspected or confirmed deep endometriosis involving the bowel, bladder or ureter.
Consider referring young women (aged 17 and under) with suspected or confirmed endometriosis to a paediatric and adolescent gynaecology service, gynaecology service or specialist endometriosis service.
When should you consider outpatient follow up in endometriosis:
Consider outpatient follow-up (with or without examination and pelvic imaging) for women with confirmed endometriosis, particularly women who choose not to have surgery, if they have:
deep endometriosis involving the bowel, bladder or ureter
OR
1 or more endometrioma that is larger than 3 cm.
