Endometriosis Flashcards
Define
Presence and growth of endometrial tissue outside the uterus
- Affects 1 in 10 women (of reproductive age), mainly 30-45y
- Risk Factors: early menarche, FHx, nulliparity, prolonged menstruation (>5 days), short menstrual cycles
o Sampson’s theory – retrograde menstruation and implantation may be the cause
Prevalence higher in WHITE women and in those with LOWER BMI
o Associations -> clear cell ovarian carcinoma > endometroid ovarian carcinoma
Pathophysiology
There are several theories for the aetiology of endometriosis:
Retrograde menstruation- represents a portal for endometrial tissue to gain exposure to peritoneal surfaces.
- Endometrial cells flow backwards from the uterine cavity, through the fallopian tubes and implant on pelvic organs
Vascular and lymphatic dissemination(mets): suggested by the presence of endometriosis pulmonary disease and endometriosis at distant sites (e.g. lungs, eyes, brain)
Metaplasia
- The endometrial tissue most commonly deposits in the pelvis, on the ovaries, Uterosacral ligaments, Pouch of Douglas , rectum and sigmoid colon, bladder, distal ureter
Pathophysiology
- Endometriosis is hormone mediated (oestrogen mediated), associated with menstruation.
The hormonal changes within the menstrual cycle:
- Induce bleeding
- Chronic inflammation
- Scar tissue formation
Types
- Superficial endometriosis - on the superficial cavities
- Nodular - deep inside
- Cystic - cysts
Risk factors
- Early menarche
- Delayed childbearing
- Nulliparity
- Positive family history
- Vaginal outflow abnormalities
- White ethnicity
- Obesity
- Autoimmune disease
- Late first sexual encounter
- Smoking
- Late menopause
Signs and Symptoms
- Cyclical or chronic pelvic pain occurring before or during menstruation
(Chronic= minimum of 6 months) PROGRESSIVELY WORSENING
- Dyspareunia (deep), dyschezia (pain on defecation)
- Dysmenorrhoea (N.B. no menorrhagia differentiates this from fibroids)
- Symptoms of extra-uterine endometriosis (i.e. rectal pain, bleeding)
- Subfertility: Due to scarring or prostaglandin over-production, this can interfere with fertilisation or implantation
Signs/ Differential diagnoses
Bimanual and speculum exam will show…
- Pelvic mass (chocolate cysts)
- Uterosacral ligament nodularity
- “guitar string” texture associated with tenderness (typical when peritoneal structures are involved)
- Fixed, retroverted uterus (Late finding- suggestive of peritoneal fibrosis and pelvic adhesions)
- May also be in chronic PID
- May be associated with a ‘frozen pelvis’
- Manifests as UTERINE TENDERNESS (V.painful esp in posterior when doing bimanual )
DDx
Adenomyosis
Leiomyomata (fibroids)
PID
Uterine myoma
Ovarian cysts (torsion rupture)
Ectopic preg
Large polyps
IBD
IBS - often associated with endometriosis
Interstitial cystitis
Investigations
- Speculum with triple swab
- Urine dip and preg test
- Blood tests (FBC - anaemia, group and save)
CA125 is increased in adenomysosis, endometriosis, pregnancy, fibroids, liver disease, ovarian cancer
Bimanual & speculum examination (findings: reduced mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions, fixed retroverted uterus = ectopic tissue on utero-sacral ligament)
1st line- Transvaginal ultrasound (TVUSS)
May show:
- Ovarian endometrioma (homogenous, low-level echoes)
- Deep pelvic endometriosis e.g. uterosacral ligament involvement (hyperechoic linear thickening)
- Rectovaginal septum involvement
Transabdominal USS
Diagnostic Laparoscopy- GOLD STANDARD for DIAGNOSIS
- Direct visualisation with biopsy-confirmed endometrial glands or stroma outside the uterine cavity
- Red vesicles or punctate marks on peritoneum = active lesions
- White scars / brown spots = less active endometriosis
- Chocolate cysts (fluid-filled sacs that can grow on the ovaries)
- Powder burn/ gun powder spot
- Thickened uterosacral ligament
- Hysterosalpingography
- Useful in patients with mullerian anomaly
- Contrast will delineate the endometrial cavity from the surrounding/ internal filling defects
Also consider:
- MRI
- 3D ultrasonography
- Rectal endoscopic ultrasonography
Management
Medical treatment of presumed endometriosis can begin if clinical examination / TVUSS normal (without need for laparoscopy) however, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:
1st line: Paracetamol/ NSAIDS short trial (i.e. 3 months)
(inhibit PG synthesis = main reason for pain)
Avoid opiates due to often co-existing constipation (IBS ± constipation often co-existent)
- Mefanamic acid - painkiller
- transexamic acid - bleeding
2nd line: COCP
- Can be used as 21 days on and 7 days off
- Can be tricycled (3 packets back to pack) then one week off
- Can also be taken without a break to induce amenorrhoea
- If bleeding causes so much pain, don’t want to bleed constantly
- If this achieves relief, can be continued for several years until pregnancy is intended
- Even if it is oestrogen dependent, you are giving much less oestrogen than you will get in the first place and mainly progesterone
2nd line: Progestogens- used to induce amenorrhoea in those CI for the COCP
- Examples: POP, implant, depot or LNG-IUS
- Progesterone causes a thin endometrium as it is secretory so helps with symptoms that way
3rd line: GnRH agonists - REFER TO SPECIALIST CARE
- Example: Leuprorelin
- Effective at relieving severity of symptoms
- Administered as a slow-release depot (lasting ≥ 1 month)
- Should NOT be used for > 6 months due to risk of osteoporosis and get menopause symptoms
- Available as multiple, daily-administered intranasal sprays
Surgical Treatment
Laparoscopy
- Excision and ablation of the inner cyst lining can be effective - main stay for fertility
- Use laser or diathermy
- Adjunct: 3 months of GnRH agonists prior to surgery
Indications:
- Patients with endometrioma
- Severe deep disease (if there is pain)
- Large endometrioma (>3cm)
- Patients who fail fertility treatment
- Risk of recurrence is as high as 30% so long-term medical therapy is often needed
NOTE: if on fertility treatment, can only have drainage as there is a risk of damaging ovarian tissue
Hysterectomy and Oophorectomy
- This should be considered in women who have completed their family and failed to respond to conservative treatments
- Hysterectomy does NOT necessarily cure the symptoms of the disease
- AFS is used to classify endometriosis to predict recurrence after surgery
Complications
Ovarian failure post-surgical intervention
Adhesion formation
- Results from the inflammatory disruption of peritoneal surfaces and are potentiated by surgical trauma
- Can lead to PAIN and BOWEL OBSTRUCTION
- Adhesiolysis predisposes to unrecognised bowel injuries- may result in post-operative complications like peritonitis or obstruction
Subfertility
IBS/ constipation
Prognosis
Pain can be managed by medical and surgical means – has varying degree of recurrence and progression
Delays in diagnosis result in untreated pain
Prognosis for sub-fertile patients with endometriosis varies and is dependent on multiple factors e.g. age, anovulation, tubal function and male factor.
Adhesion formation can impact fertility
PACES
Endometriosis is a condition where the tissue that lines the womb starts appearing outside the womb
Management can be medical or surgical
- Analgesia such as Mefanamic acid, paracetamol
- Hormonal - COCP, IUS/depot
- Surgical - can be when medical management fails or want to conserve fertility
- Excision and ablation of the inner cyst lining using diathermy or laser
- Curative approach of total hysterectomy and bilat salpingo-oopherectomy
