Endometriosis Flashcards
Incidence of Endometriosis in reproductive age women?
6-10%
Endometriosis is present in what percentage of women with infertility?
50%
Two common presentations of endometriosis
Pelvic Pain
Infertility
Familial component to endo?
Yes! Hx of first degree family member puts you at 8x higher risk for developing endometriosis
Most common site of endometriosis implants?
- Ovaries
- A/P Cul De Sac
- Posterior Broad Ligament
*Uterosacral ligament involvement usually signifies more significant disease
Pathogenesis of endometriosis?
- Increased IL-1, IL-6, IL-8, TNF > Increased COX-2 > increased prostaglandins
- Increase aromatase activity = over production of estrogen
- Progesterone resistance = amplifies estrogen effect
Pain is related to what components of endometriosis lesions?
Directly related to depth of lesion and involvement of neuro structures….does not correlate to “amount” of endo
Most predictable signs of deeply infiltrating endo?
Painful defecation during menses
Severe Dyspareunia
First line treatment for Endo?
NSAIDs, start 1-2 days before onset of menses and continue through first 2-3 days of bleeding
Second line treatment for Endo?
Combined OCPs (or just norethindrone which has been shown to be equally as effective)
What if patient fails NSAIDs and OCPs?
Empiric therapy with a 3 month course of GnRH agonist is appropriate
Does add back therapy affect effectiveness of Lupron?
Nope! Start add back therapy right away…. equally as effective at treating symptoms and less side effects/bone loss
First line treatment for extra pelvic disease?
GnRH agonist
Maximum length of treatment for GnRH agonist?
6 months
Can do 12 months if using add back therapy at 6 months
Does surgical removal improve infertility?
Yes!
Laparoscopic treatment of minimal and moderate endometriosis improves the pregnancy and live birth rates in couples with otherwise unexplained infertility.
Surgical management of endometriosis can improve pregnancy rates dramatically. Excision of an endometrioma results in pregnancy rate of 60.9%, whereas drainage and ablation of an endometrioma results in a pregnancy rate of 23.4%
In a woman with chronic pelvic pain that has a hyst and retains her ovary(ies) what is the likelihood she will require another operation due to continued pelvic pain?
30%
Endometriosis is associated with which type of epithelial ovarian cancer?
Clear Cell
Hobnail Cells
Endo recurrence risk in someone who had a bilateral oophorectomy?
15%
Most common location for lesions during reoperation after TLH BSO?
Small and large bowel
Common histopathology for endo lesions?
Endometrial epithelium, glands and stroma
Hemosiderin-laden macrophages
What size endometriomas should be removed in a patient with infertility to improve pregnancy rates?
3 cm or larger
How much does hx of a first degree relative with endometriosis increase your risk?
8x
FDA approved medication for add back therapy with Lupron?
Norethindrone
When is a presacral neuroectomy used for treatment of endo?
Failed medical management
Only useful for treatment of midline pain
Associated with bowel and bladder dysfunction
What is central sensitization?
Perpetuates chronic pain by amplifying pain perception due to abnormal central processing of sensory information
Differential diagnosis for chronic pelvic pain?
“When I first saw them I was thinking about my broad differential, both Gyn and Non Gyn causes including: GU, GI, Musculoskeletal, and neurological or psychological causes”
GU: Chronic UTI, interstitial cystitis
GI: IBS, constipation, celiac/chrons
MS: Hypertonic pelvic floor
Neuro: neuroalgia
Psych: Anxiety, depression, abuse
Treatment options for chronic pelvic pain
Pelvic Floor PT
CBT
Neuropathic pain medications (SNRI, gabapentin)
Trigger point injections
Acupuncture/Yoga
DO NOT GIVE OPIOIDS
