Endometriosis

Question 1

What is endometriosis?

Answer 1

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.

Question 3

What is adenomyosis?

Answer 3

Endometrial tissue within the myometrium (muscle layer) of the uterus.

Question 4

What are theories of endometriosis aetiology?

Answer 4

1. Retrograde menstruation
2. Embryonic cells later develop into ectopic endometrial tissue
3. Spread through lymphatic system
4. Metaplasia

Question 5

How is the pain of endometriosis characterised?

Answer 5

Cyclical, dull, heavy or burning pain that occurs during menstruation.

Question 6

How can endometriosis lead to blood in urine or stools?

Answer 6

Deposits of endometriosis in bladder or bowel.

Question 7

What type of pain do adhesions cause?

Answer 7

Chronic, non-cyclical pain that can be sharp, stabbing, or pulling and associated with nausea.

Question 8

What are symptoms of endometriosis?

Answer 8

1. Cyclical abdominal or pelvic pain
2. Deep dyspareunia (pain on deep sexual intercourse)
3. Dysmenorrhoea (painful periods)
4. Infertility
5. Cyclical bleeding from other sites, such as haematuria
6. Urinary or bowel symptoms

Question 9

What might examination of a women with endometriosis show?

Answer 9

1. Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
2. A fixed cervix on bimanual examination
3. Tenderness in the vagina, cervix and adnexa

Question 10

What are “chocolate cysts”?

Answer 10

Endometriomas in the ovaries.

Question 11

What is the gold standard way to diagnose abdominal and pelvic endometriosis?

Answer 11

Laparoscopic surgery with biopsy.

Question 12

Outline the 4 stages of endometriosis (ASRM system).

Answer 12

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

1. Establishing a diagnosis
2. Providing a clear explanation
3. Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
4. Analgesia as required for pain (NSAIDs and paracetamol first line)

Question 14

What hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy?

Answer 14

1. Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
2. Progesterone only pill
3. Medroxyprogesterone acetate injection (e.g. Depo-Provera)
4. Nexplanon implant
5. Mirena coil
6. GnRH agonists

Question 15

What are two surgical management options for endometriosis?

Answer 15

1. Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adensiolysis)
2. Hysterectomy and bilateral salpingo-oopherectomy

Question 16

Will hormonal therapies improve fertility?

Answer 16

No

Question 17

Will laparoscopic treatment improve fertility?

Answer 17

Can improve

Question 18

How do hormonal medications help reduce cyclical endometriosis pain?

Answer 18

Stop ovulation and reduce endometrial thickening.

Question 19

When does the cyclical pain of endometriosis tend to improve for patients?

Answer 19

After menopause when sex hormones are reduced.

Question 20

How can GnRH agonists be used to manage endometriosis?

Answer 20

Include menopause-like state by shutting down ovaries temporarily.

Question 21

What are side effects of GnRH agonists?

Answer 21

Inducing menopause side effects e.g. hot flushes, night sweats, risk of osteoporosis.

Question 22

Name two GnRH agonists.

Answer 22

1. Goserelin (Zoladex)

2. Leuprorelin (Prostap)