Clinical Approach To Endometrosis

Question 1

Endometriosis and adenomyosis

Answer 1

Endometriosis = Inflammation of the endometrium
- can really be any infectious agent

Adenomyosis = inflammation and infection of glands and stroma tissue located in the myometrium

Question 2

Types of uterine cancer

Answer 2

Endometrial carcinoma

Leiomyosarcoma

Mixed mullarian tumors

Question 3

Endometriosis

Answer 3

Atopic uterus/gland tissues that aren’t in the uterus but usually still in the pelvis somewhere

Is a benign inflammatory disease usually

• *however they are estrogen-dependent so symptoms often get worse during the cycle**
• does get better during pregnancy if the patient can get pregnant

Pathophysiology = abnormal cell proliferation and apoptosis causes metastatic endometrial tissues

• also retrograde menstruation (Sampson theory) is the leading theory behind this. The endometrial cells migrate in retrograde fashion to the Fallopian tubes and peritoneal cavity. However females without menarche can still et this so it doesn’t explain everything
• also increased sensory nerve fibers and sensitivity to inflammation occurs

Increased risk for (doesn’t predispose to these but there is an increase risk of these developing by itself)

• ovarian caricnoma
• atherosclerosis
• MIs/CAD
• endometrial carcinoma
• ectopic pregnancy
• spontaneous abortion
• placenta previa
• preterm delivery

does have high risk for infertility

Question 4

Most common locations of endometriosis

Answer 4

Ovaries (most common)

Fallopian tubes

Cervix

Vagina

Cecum

Bladder/ureter

Abdominal wall

Rectum/colon/appendix

Peritoneum

Question 5

4 subtypes of endometriosis

Answer 5

1) superifical peritoneal
- most benign form
- endometrial tissues are on peritoneal surface

2) ovarian
- endometrial tissue within ovary
- causes a hematoma “chocolate cyst”
- often shows adhesions and fibrotic walls

3) deeply infiltrating
- solid endometrial masses located more than 0.5cm deep to the peritoneum
- also the endometrial tissues invades organs**
- rectum, colon, bladder, ureters

4) abdominal wall

Question 6

Clinical presentation of endometriosis

Answer 6

Chronic pelvic pain

Dysmenorrhea

Dyspareunia

Menorrhagia

Infertility

Ovarian mass

Urinary frequency/urgency, dysuria and hematuria

Diarrhea constipation

Painful defecation

Abdominal wall pain

MOST common in 20-30s

Question 7

Work up for endometriosis

Answer 7

Physical exam may show

• adnexal masses/tenderness
• vaginal pain on exam
• cervical and/or uterine anatomical displacement

Pelvic ultrasound shows:

• ovarian cysts
• extra-uterine nodules

Definitive diagnosis = laparoscopy with tissue biopsy

• *there is no specific lab tests but the CA-125 can be elevated (CARCINOMA ANTIGEN 125)
• however this is a nonspecific cancer, pregnancy, mensturation or endometriosis marker**

Question 8

Surgical staging of endometriosis

Answer 8

Stage 1 = minimal disease and isolated implants

Stage 2 = mild disease with implants <5cm and no adhesions

Stage 3 = moderate disease with implants that are invasive yet superficial
- there are no adhesions though

Stage 4 = severe disease with several superficial and invasive implants
- there IS adhesions though

**DOES NOT correlate with the symptoms of the disease

Question 9

Treatment of endometriosis

Answer 9

First line = NSAIDs and OCPs (combined estrogen/progesterone only)

2nd line = NSAIDs and depo shot

3rd line = GnRH agonists/antagonists (leuprolide)

4th line = aromatase inhibitors

5th line = laparoscopy and (+/-) hysterectomy

must consider symptoms and extent of the disease (if very serious = may move to further liens immediately)