Endometriosis Flashcards
what is endometriosis
A condition where endometrial tissue grows outside endometrium
what is the most common type of endometriosis
pelvic endometriosis
what is a less common type of endo
extrapelvic endo
what is the genetic risk with endo
first degree relative on mother’s side = 7-10x risk
what is the suspected hormonal pathogenesis of endo
may have ↓ response to progesterone on endometrium from ↓ receptors on endometrial tissue/ implants = inability to cause apoptosis of endometrial tissues
what is the suspected mechnical pathogenesis of endo
cervical stenosis = retrograde menstruation
what is the suspected immunological pathogenesis of endo
△ T+B cell function, lvl of cytokines and GF in endometrial tissue
Immunologic abnormality prevents clearance of endometrial tissue fragments from exiting peritoneum OR
Immune system stimulation caused by presence of endometrial tissue in peritoneum = increased inflammation
what is the mullerian embryonic theory of endo
during embryonic development, remnants present in other parts of the body which can form endometrial tissue
what is the lymphatic and vascular metastasis that can cause endo
extrapelvic- transport of lesions through vascular/ lymph system
what is the coelomic metaplasia theory of endo
metaplasia of cells in mesothelial lining of the organs = transforms normal peritoneal cells into endometrium like
what is the endometrial stem cell implantation that can lead to endo
endo cells originate from stem cells
sx of endo
Pain: pelvic, abdominal, lower back
Dysmenorrhea + pain with ovulation
Spotting or bleeding b/w periods
GI sx (more if GIT involved): painful BM, diarrhea during period, abd bloating
Painful urination or increased urgency (if bladder involved
Heavy periods
endo symptoms are more linked to
1. severity of implants
2. placement of implants
2
endo sx often resolve with
menopause
an endo diagnosis can be based on
S/S
Transvaginal ultrasound (for deep implants or abnormal sites)
Laparoscopy (+confirmed with biopsy) or CT or MRI
Sometimes CA-125 but is not specific for endo and more for ovarian cancers (may be increased if endo on ovaries)
T or F: staging matches well with severity of sx
F
pharm classes used for endo
NSAIDs
CHC
progestins
LNG-IUS
danazol
GnRH agonists and antagonists
what do progestins do in endo
atrophy of endometrial tissues
what is dienogest used for in endo
to manage pelvic pain + shown to be as effective as leuprolide
what is danazol
Androgen derived from 17-a ethinyl testosterone = androgenic effects
danazol MOA
Suppresses pituitary ovarian axis = ↓FSH and LH = directly inhibits ovarian steroidogenesis = ↓ E = atrophy of endometrial implants
danazol AEs
acne, weight gain, fluid retention, hirsutism, deepening of voice, ↑LFT, ↓HDL, ↑LDL
Most reversible, except for lowering voice
what is contraindicated for danazol
severe liver disease, hyperlipidemia
what to monitor for if on danazol
LFTs if >6mths
GnRH agonists MOA
Continuous GnrH release (vs normal pulsatile) = gonadotrophin desensitization + ↓ receptors = ↓FSH, LH = ↓ estrogen = medical menopause
what is a counselling point for GnRH
will get worse before it gets better
response rate of GnRH for endo
85-100% of pts in 4-8wks
how long are GnRH recommended to be used for
<6mhs due to BMD loss
Buserelin acetate is a
nasal spray or SQ inj
Goserelin acetate is a
depot SQ
Leuprolide acetate is a
depot IM
Nafarelin acetate is a
nasal spray
Triptorelin pamoate is a
depot IM
AEs of GnRH
menopausal sx (medical oopherectomy)- vasomotor sx (hot flashes, night sweats), vaginal dryness, headache, ↓ libido, insomnia, ↓ in BMD (1% per mth of use)
Depot has greater menopausal sx + bone loss comp short acting
what form of GnRH has greater menopausal sx and bone loss
depot
how to lower GnRH AEs
add back E and P
what is elagolis
direct antagonist of GnRH = decreased FSH/LY = lowered E
elagolis AEs
vasomotor sx,. Vaginal dryness, headache, ↓ libido, insomnia, ↓ BMD (reversible with d/c), ↑ lipids
add back therapy is required for elagolis doses above
200mg bid
are aromatase inhibitors used in endo
only when not responding to other therapies + still in investigation
what is conservative surgery for endo
laparoscopy
what surgery can be done for endo in women who still want children
laparoscope
recurrance rate of endo from laparoscope
20-40%/yr
what surgery can be used for chronic pelvic pain
LUNA: laparoscopic uterine nerve ablation
Presacral neurectomy- in conjunction with conservative surgery
what is radical surgery for endo
Hysterectomy +/- removal of both ovaries
T or F: there can still be recurrence of endo even after a hysterectomy
T- 3-5% of pts
how long should each therapy for endo be trialed before moving on
2-3mths
what is first line for endo
CHC + NSAIDs or progestins
what is second line for endo
LNG-IUS, GnRH agonist + add back HT or GnRH antagonist
what is third line for endo
laparoscopy
what is 4th line for endo
surgical tx
what are some alt options for endo
Neuromodulators for chronic pain :TCAs, SNRIs, gabapentinoids (gabapentin, pregabalin)
Muscle relaxants
Complementary therapies: lifestyle (exercise, diet, sleep, mindfulness, CBT), pelvic floor physiotherapy
what 3 meds have the best evidence for endo
progestins
danazol
GnRH agonists
which agents for endo treatment most commonly cause BTB
progestin and danazol
