Endometriosis Flashcards
Define endometriosis.
Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature.
How common is endometriosis?
Around 10% of women of a reproductive age have a degree of endometriosis.
What are the risk factors for endometriosis?
- Early menarche.
- Late menopause.
- Delayed childbearing.
- Nulliparity.
- Family history.
- Vaginal outflow obstruction.
- White ethnicity.
- Low BMI
- Autoimmune disease
- Late first sexual encounter.
- Smoking.
What causes endometriosis?
Unknown but may be:
- Retrograde menstruation - endometrial cells flow backwards from uterus, through fallopian tubes and implant on pelvic organs
- Lymphatic or circulatory dissemination of endometriotic tissue
- Genetic predisposition
- Metaplasia - cells change into endometrial-type alone
- Immune dysfunction
- Environemntal factors
What are the clinical features of endometriosis? What are some features on examination?
- Chronic pelvic pain (at least 6 months, cyclical or continuous)
- Dysmenorrhoea - pain may start days before bleeding
- Dyspareunia
- GI symptoms e.g. painful bowel moevements (period related or cyclical)
- Infertility
O/E:
- Reduced organ mobility and enlargement
- Tender nodularityo on posterior vaginal fornix
- Visible vaginal endometriotic tissues
What are the long term complications of endometriosis?
Endometriomas (ovarian cysts with blood and encometriosis-like tissue)
Fertility problems (endometriosis prevalence in infertile women is almost x10 higher)
Adhesions –> chronic pelvic pain, bowel obstruction, reduced QoL
What is the prognosis of endometriosis?
- May be chronic throughout reproductive life
- Symptoms may be well controlled
- Sometimes regressive, progressive and sometimes stable in nature
What are some differentials for endometriosis?
Include these categories:
- Uterine
- Gynaecological
- Urological
- Gastrointestinal
- Adenomyosis or uterine fibroids - also causes dysmenorrhoea and HMB
- Primary dysmenorrhoea
- PID - pain, dyspareunia, malodorous discharge
- Ectopic pregnancy
- Cystitis/UTI
- IBS/IBD
What is the gold-standard investigation for diagnosis of endometriosis?
Laparoscopy
There is little role for any investigations in primary care e.g. US. If the symptoms are significant enough, refer for definitive diagnosis.
List the categories of medical and surgical treatment that can be offerred for endometriosis.
Medical:
- Analgesia - NSAIDs or paracetamol
- COCP
- Progestogens
- GnRH agonists e..g. Leuprorelin
Surgical:
- Fertility sparing: laparoscopic excision or ablation + 3 months GnRH agonists prior to surgery
- Completed family: Hysterectomy and oophrectomy
Why should opiates/codeine be avoided in endometriosis?
If coexisting IBS is present then it could exacerbate it
What COCP regimen may be most effective in endometriosis? What if the COCP is not effective?
Tricycled (3 packets taken back to back)
OR without break
If COCP not effective, offer treatment for other coexisting conditions e.g. IBS and change the medical management.
What progestogens are affective in endometriosis?
- Medroxyprogesterone acetate depot
- IUS levonogestrel
- POP
- Implant (Nexplanon)
How does Leuprorelin act in endometriosis to relieve symptoms? What form is it administered in?
Induces ‘perimenopause’ due to low oestrogen levels
Usually given in slwo-release depots lasting ~1 months ir intranasal spray which is administered several times daily
Cannot be used for >6 months
Why can GnRH analogues not be used for >6 months?
Risk of osteoporosis
How high is recurrence of endometriosis post surgery?
30% risk of recurrence so long-term medical therapy is often needed
Does hysterectomy and oophrectomy cure all symptoms of endometriosis?
Not necessarily
How would you counsel a patient about endometriosis?
Diagnosis: Cells of the lining of the womb found outside of the womb. Causes chronic pain, pain during sexual intercourse, and other symptoms e.g. painful bowel movements.
It is common - found in 10% of women of reproductive age
Cause is largely unknown and treatment is primarily symptomatic but can be treated with a contraceptive pill if you wish. Risk factors for endometriosis include FH, early menarche, nulliparity, prolonged menstruation and short menstrual cycles.
Complications include infertility and adhesions in abdomen which may cause pain.
Treatment includes pain relief and also depends on if you have completed your family or if you are trying for a baby.
Prognosis is diffcult to say - some regress, others remain stable
