Endometriosis

Question 1

What is endometriosis?

Answer 1

-endometriosis is a condition where there is ectopic endometrial tissue outside the uterus

Question 2

What is an endometrioma?

Answer 2

• a lump of endometrial tissue outside the uterus

- endometriomas in ovaries are often called chocolate cysts

Question 3

What does adenomyosis refer to?

Answer 3

-refers to endometrial tissue within the myometrium(muscle layer of the uterus

Question 4

Describe the aetiology of endometriosis?

Answer 4

• exact cause is unclear
• some genetic association
• retrograde menstruation is theorised to be a potential cause

Question 5

What is the main symptom of endometriosis and what is the pathophysiology behind it?

Answer 5

• pelvic pain
• the endometrial tissue lying outside the uterus in endometriosis responds the same to hormones as the tissue inside the uterus
• this means during menstruation the tissue outside also sheds its lining and bleeds which causes irritation and inflammation of the tissues around the sites of endometriosis

Question 6

How can endometriosis lead to blood in urine or stools?

Answer 6

-there can be deposits of endometrial tissue in the bladder and bowel which bleeds during menstruation

Question 7

How can the bleeding at the endometriosis sites lead to adhesions?

Answer 7

• bleeding leads to inflammation which damages and develops scar tissue that binds organs together
• e.g ovaries can become fixed to peritoneum or uterus may be fixed to the bowel
• adhesions are associated with chronic, non-cyclical that can be sharp/stabbing and with nausea

Question 8

What might endometriosis affecting the sexual organs lead to?

Answer 8

Infertility

Question 9

Describe the presentation of endometriosis

Answer 9

• can be asymptomatic
• cyclical abdo/pelvic pain
• deep dyspareunia (pain on deep sexual intercourse)
• dysmenorrhoea (painful periods)
• infertility
• cyclical bleeding from other sites, such as haematuria

-Also can have urinary and bowel symptoms

Question 10

What may examination reveal in endometriosis?

Answer 10

• endometrial tissue visible in vagina on speculum exam, particularly in posterior fornix
• a fixed cervix on bimanual exam
• tenderness in vagina, cervix and adnexa

Question 11

What investigations would you to do diagnose endometriosis?

Answer 11

• pelvic US -> may reveal large endometriomas and chocolate cysts but often unremarkable
• Laparoscopic surgery (gold standard) -> definitive as biopsy of lesions can be taken laparoscopically and also deposits can be removed to improve symptoms

Question 12

What is the staging system that can be used for endometriosis?

Answer 12

ASRM staging system:

• Stage 1: Small superficial lesions
• Stage 2: Mild, but deeper lesions than stage 1
• Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
• Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

Question 13

What does the initial management of endometriosis involve?

Answer 13

• establishing diagnosis
• providing a clear explanation
• analgesia as required for pain (NSAIDs and paracetamol first line

Question 14

What are the hormonal management options for endometriosis?

Answer 14

-these can be tried before establishing diagnosis with laparoscopy

• Combined OCP
• Progesterone only pill
• Medroxyprogesterone acetate injection e.g Depo-provera
• nexplanon implant
• mirena coil
• gnRH agonists

Question 15

What are the surgical management options for endometriosis?

Answer 15

• Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions
• Hysterectomy

-laparoscopic treatment may improve fertility , while hormonal treament improves symptoms but not fertility

Question 16

How do hormonal managements improve cyclical pain?

Answer 16

• they stop ovulation and reduce endometrial thickening - all expect gnRH agonists
• gnRh agonists induce a menopause like state, temporarily shutting down the ovaries –> but risk of osteoporisis