Endometriosis

Question 1

Incidence of Endometriosis in reproductive age women?

Answer 1

6-10%

Question 2

Endometriosis is present in what percentage of women with infertility?

Answer 2

50%

Question 3

Two common presentations of endometriosis

Answer 3

Pelvic Pain

Infertility

Question 4

Familial component to endo?

Answer 4

Yes! Hx of first degree family member puts you at 8x higher risk for developing endometriosis

Question 5

Most common site of endometriosis implants?

Answer 5

1. Ovaries
2. A/P Cul De Sac
3. Posterior Broad Ligament

*Uterosacral ligament involvement usually signifies more significant disease

Question 6

Pathogenesis of endometriosis?

Answer 6

• 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

Question 7

Pain is related to what components of endometriosis lesions?

Answer 7

Directly related to depth of lesion and involvement of neuro structures….does not correlate to “amount” of endo

Question 8

Most predictable signs of deeply infiltrating endo?

Answer 8

Painful defecation during menses

Severe Dyspareunia

Question 9

First line treatment for Endo?

Answer 9

NSAIDs, start 1-2 days before onset of menses and continue through first 2-3 days of bleeding

Question 10

Second line treatment for Endo?

Answer 10

Combined OCPs (or just norethindrone which has been shown to be equally as effective)

Question 11

What if patient fails NSAIDs and OCPs?

Answer 11

Empiric therapy with a 3 month course of GnRH agonist is appropriate

Question 12

Does add back therapy affect effectiveness of Lupron?

Answer 12

Nope! Start add back therapy right away…. equally as effective at treating symptoms and less side effects/bone loss

Question 13

First line treatment for extra pelvic disease?

Answer 13

GnRH agonist

Question 14

Maximum length of treatment for GnRH agonist?

Answer 14

6 months

Can do 12 months if using add back therapy at 6 months

Question 15

Does surgical removal improve infertility?

Answer 15

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%

Question 16

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?

Answer 16

30%

Question 17

Endometriosis is associated with which type of epithelial ovarian cancer?

Answer 17

Clear Cell

Hobnail Cells

Question 18

Endo recurrence risk in someone who had a bilateral oophorectomy?

Answer 18

15%

Question 19

Most common location for lesions during reoperation after TLH BSO?

Answer 19

Small and large bowel

Question 20

Common histopathology for endo lesions?

Answer 20

Endometrial epithelium, glands and stroma

Hemosiderin-laden macrophages

Question 21

What size endometriomas should be removed in a patient with infertility to improve pregnancy rates?

Answer 21

3 cm or larger

Question 22

How much does hx of a first degree relative with endometriosis increase your risk?

Answer 22

8x

Question 23

FDA approved medication for add back therapy with Lupron?

Answer 23

Norethindrone

Question 24

When is a presacral neuroectomy used for treatment of endo?

Answer 24

Failed medical management
Only useful for treatment of midline pain

Associated with bowel and bladder dysfunction

Question 25

What is central sensitization?

Answer 25

Perpetuates chronic pain by amplifying pain perception due to abnormal central processing of sensory information

Question 26

Differential diagnosis for chronic pelvic pain?

Answer 26

“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

Question 27

Treatment options for chronic pelvic pain

Answer 27

Pelvic Floor PT
CBT
Neuropathic pain medications (SNRI, gabapentin)
Trigger point injections
Acupuncture/Yoga

DO NOT GIVE OPIOIDS