Endometriosis

Question 1

What is endometriosis?

Answer 1

Ectopic endometrial tissue growth outside of the uterine cavity. It’s a chronic and debilitating condition, and just like the normal endometrial tissue in the uterus, endometriosis responds to cyclical hormones that are associated with menstruation. Therefore, the hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation

Question 2

Where are endometriotic deposits most commonly found in the female body?

Answer 2

The deposits are most commonly found on pelvic structures:

Ovaries (most frequently affected) –> if complicated lead to chocolate cyst

Uterosacral ligaments

Recto-uterine pouch (pouch of Douglas)

Rectum and sigmoid colon, peritoneal cavity

Bladder

Distal ureter

Extrapelvic deposits (rare) such as bowel, diaphragm, umbilicus, pleural cavity or the brain

Question 3

What are the causes/ pathophysiology of endometriosis?

Answer 3

Cause is unknown. However, several theories have been proposed to explain the underlying mechanisms for the development of the disease:

• Retrograde menstruation (Sampson’s theory)
  
  • This is where endometrial cells flow backwards from the uterine cavity, through (and exit) the fallopian tubes, and implant on pelvic organs, where they seed and grow
  • This does not explain why endometriosis occurs in some women after hysterectomy or, rarely, in some men following prolonged hormonal (oestrogen) therapy
• Lymphatic or circulatory dissemination
  
  • This is where endometriotic tissue maybe able to travel to distant sites (e.g. lungs, eyes, and brain) through the lymphatic system or the bloodstream
• Coelomic metaplasia (Meyer’s theory)
  
  • This describes a process by which cells of the peritoneum, which come from the same cell line as the endometrial cells, can transform spontaneously into endometrial tissues
  • This explains how in rare cases women who underwent hysterectomy can still develop endometriosis
• Immune dysfunction
  
  • This is where B and T cells don’t respond to endometrial implants and allow it to grow

Question 4

Give 5 risk factors for endometriosis

Answer 4

Early menarche

Late menopause

Delayed childbearing (a social phenomenon where women are delaying having children)

Nulliparity (never had children before)

FHx

Vaginal outflow obstruction

White ethnicity

Low BMI

Smoking

Question 5

Epidemiology of endometriosis:

How common is endometriosis?

Answer 5

Endometriosis affects 10% of women in their reproductive years

Prevalence is significantly higher in women with inferility (up to 50%)

Endometriosis is the 2nd most common gynaecological condition in women after fibroids!

Question 6

Give 5 complications of endometriosis

Answer 6

Complications of endometriosis

• Endometriomas (also called ‘chocolate cysts’ due to the appearance of the contained, old and altered blood) - they are ovarian cysts that contain blood and endometriosis-like tissue. They may rupture and affect fertility by causing distortion of pelvic anatomy - see image
• Infertility
  
  • Mechanisms linking endometriosis and infertility are poorly understood
  • Severe disease can cause tubal adhesions (resulting in marked distortion of pelvic anatomy and pelvic pain), reduced ovarian reserve and oocyte and embryo quality, and poor implantation. It also disturbs the function of the fallopian tube, embryo transport, and the eutopic endometrium
• Adhesions formation –> chronic pelvic pain
• Bowel obstruction - can be due to adhesion formation or a circumferential endometriotic deposit
• Chronic pain - in some women, pain from endometriosis may become chronic even when visible disease has been removed
• Depression

Question 7

What are the clinical features of endometriosis?

Answer 7

Presentations:

Endometriosis responds to cyclical hormonal changes and bleeds at menstruation! - pain starts before the onset of menstruation and resolves by the end of menstruation!

• Chronic pelvic pain (defined as a minimum of 6 months of cyclical or continuous pain)
• Dysmenorrhoea - pain often starts days before bleeding
• Deep dyspareunia - deep pain during or after penetrative sex
• Menorrhagia
• IMB and PCB if endometriotic deposits are in and around the cervix
• Period-related or cyclical GI symptoms e.g. dyschezia (painful bowel movements), bloating, N&V
• Period-related or cyclical urinary symptoms e.g. dysuria, haematuria, LUTS (frequency, urgency …)
• Infertility/ subfertility (exact mechanism not known)
• Rarely, symptoms of distant deposits e.g. catamenial pneumothorax (pleural membrane) and catamenial epilepsy, epistaxis and rectal bleeding
• Perform an abdominal and pelvic examination to identify abdominal masses and pelvic signs:
  
  • Reduced organ mobility
  • Uterine/ ovarian enlargement
  • Tender nodularity in the posterior vaginal fornix
  • Visible vaginal endometriotic lesions
  • A fixed, retroverted uterus
  • Thickened uterosacral ligaments
  • Uterine and forniceal tenderness

Question 8

Give 5 differential diagnoses for endometriosis

Answer 8

Differential diagnoses for endometriosis

Uterine conditions

• Uterine fibroids or adenomyosis
  
  • Typically causes lower abdominal pain and menorrhagia
• Primary dysmenorrhoea
  
  • Painful cramping, usually in lower abdomen, which occurs shortly before or during menstruation, or both. It occurs in young females in the absence of any identifiable pelvic pathology
• Uterine myoma
  
  • Usually asymptomatic but often present with heavy or irregular menstrual bleeding

Gynaecological conditions

• PID
• Ectopic pregnancy
• Benign ovarian cyst
• Ovarian cancer - often weight gain despite lack of appetite

Urological conditions

• Interstitial cystitis
• Recurrent UTIs

GI conditions

• IBS
• Appendicitis
• Gastroenteritis
• Coeliac disease

Question 9

What investigations would you like to do for a woman with endometriosis?

Answer 9

Ix:

• Laparoscopy - gold standard for the diagnosis of endometriosis
  
  • Require GA
  • During surgery, a systematic review of pelvic structures is conducted + histology samples taken from suspected endometriosis deposits
    
    • May show powder burn deposits or red flame lesions. When endometriosis is not active, it can result in adhesions and scarring
    • Peritoneal defects in advanced endometriosis
• Transvaginal USS - usually carried out as an initial investigation in primary care
  
  • It can identify likely endometriosis and exclude other causes of presentation
• MRI
  
  • NOT 1st line
  • Used in those with suspected deep endometriosis, particularly affecting the bowel, bladder, or ureter

Question 10

Transvaginal vs transabdominal USS

Answer 10

See image

Question 11

How do you manage women with endometriosis?

Answer 11

Mx:

Primary care

• Referral to a gynaecology service for USS (if not already completed) and gynaecology review if the woman has:
  
  • Severe, persistent, or recurrent symptoms of endometriosis
  • Pelvic signs of endometriosis
  • Mx in primary care is ineffective i.e. analgesia or hormonal treatment doesn’t improve symptoms
  • Fertility issues
• Referral to a specialist endometriosis service (endometriosis centre) if the woman has suspected deep endometriosis involving the bowel, bladder, or ureter
• Pain management
  
  • 1st line - NSAIDs and/or paracetamol
  • 2nd line - Offer hormonal treatment, options include:
    
    • COCP to suppress ovulation and thin/ shrink the endometriotic spots
    • POP
    • Implant (Nexplanon) - A small flexible plastic rod that’s placed under the skin in your upper arm. It releases progesterone into your blood to prevent pregnancy and lasts for 3 yrs
    • Progesterone depot injection
    • Levonorgestrel intrauterine system (Mirena coil/ LNG-IUS)
  • (DO NOT OFFER HORMONAL TREATMENT TO WOMEN WITH ENDOMETRIOSIS WHO ARE TRYING TO CONCEIVE)
• Support individual needs
  
  • Depression and anxiety maybe caused or exacerbated by endometriosis. This should be recognised and treated promptly

Secondary care

• Surgery
  
  • Often the diagnostic laparoscopy (diathermy, laser) will also be used for therapeutic intervention. In particular peritoneal endometriosis and uncomplicated endometriomas maybe treated
    
    • Excision or ablation can be used to remove the ectopic endometrial tissue in the peritoneum, uterine muscle and pouch of Douglas to reduce pain
  • For those with deep endometriosis affecting the bowel, bladder, or ureter –> 3 months of GnRH agonists maybe given pre-operatively
  • For those women whose family has been completed but are suffering from menorrhagia or adenomyosis that have not responded to other treatments –> Total abdominal hysterectomy (TAH) + Bilateral salpingo-oophorectomy (BSO) maybe the ultimate treatment. Young patients will need cc-HRT to replace the hormones until the age of menopause to prevent the stimulation of endometriotic spots
    
    • Risk of bladder, ureteric and bowel injury
• Management of infertility
  
  • Offer excision/ ablation of endometriosis + adhesiolysis for endometriosis not involving the bowel, bladder or ureter
  • Ovarian cystectomy with excision of the cyst wall for endometriomas
    
    • Prior to this a woman ovarian reserve should be considered
  • If the above doesn’t help –> assisted reproduction techniques

Question 12

A patient presents to you with secondary dysmenorrhoea in a GP clinic, what should you do?

Answer 12

REFER ALL PATIENTS WITH SECONDARY DYSMENORRHOEA TO GYNAECOLOGY FOR IX!