endometriosis Flashcards
What is Endometriosis
chronic inflammatory condition caused by growth of endometrial tissue in ectopic locations
estrogen-dependent disease
what is the incidence of endometriosis
2nd to fibroids in frequency
commonly diagnosed 25-30yo
10% of reproductive aged people affected
what is the challenge with diagnosing endometriosis?
the sx are non-specific
there is no correlation w/ #, location, extent. this creates a long differential list
limited diagnostic testing
factors INCREASING risk of endometriosis
anything that makes you bleed more
ex: long heavy flow, short cycles, early menarche, late menopause, outflow obstruction, delayed or no pregnancy, LOW BMI, high alcohol or caffeine
factors LOWERING risk of endometriosis
reduced estrogen
menstrual d/o
less BODY FAT
MORE smoking
pregnancy or contraceptives
List the 7 current theories of endometriosis etiology
transplantation/ retrograde menstruation theory
tranformation theory
immunologic theory
genetic theory
embryonic theory
environmental
cell adhesion factors theory
what is the most widely accepted etiology theory? explain it.
transplantation theory- endometrial tissue is refluxed through fallopian tubes and implants elsewhere
what are some things we’ve seen that supports the most widely accepted theory
we’ve found endometrial tissue in brain, lungs, etc
this is evidence of lymphatic and vascular metastases
4 most common symptoms of endometriosis
chronic pelvic pain
dysmenorrhea usually before menstruation
dyspareunia
infertility or sub-fertility
what is dyspareunia
genital pain before, during or after sex
what is dysmenorrhea
painful periods
relationship between disease & symptom severity
they are not directly equated! someone can have really bad symptoms and not a bad disease and someone can have mild sx with a really bad disease
less common sx of endometriosis
spotting, low back pain w/ menses
dysuria, hematuria, frequent urination
rectal pain or dyschezia
generalized sx– nausea, low fever, fatigue, bloating, etc
what is dyschezia
painful shits
5 things pain could be related to
bleeding
inflammation–fibrosis– adhesions
hormones or chemicals from lesions
cysts
nerve entrapment
what might you fight on PE with advanced EM?
nodules, adhesions, fixed retroverted uterus, bluish lesions
what is the best time of cycle to do speculum exam if suspicious of endometriosis?
right before or in early menses because everything is worse
how is endometriosis diagnosed?
mostly from exclusion and clinical presentation
can do definitive diagnosis
what is required for definitive diagnosis?
visualization and histologic confirmation (biopsy) via laparoscopy
what are two helpful imaging studies for diagnosis?
transvaginal US–initial imaging
MRI for individual lesions
what are you looking for with a transvaginal US?
look for endometrial cyst (cyst on ovary) and endometriomas (chocolate cyst on ovary)
when do you use MRI?
deep infiltrating endometriosis (nodules)
what are the two goals of treatment?
relieve pain
improve fertility
what are the 3 first line type of medications?
NSAIDs, acetaminophen, antidepressants
Contraceptives
Progestins
how do contraceptives treat endometriosis? which contraceptives can do this?
slows growth, decreases likelihood of tissue reflex; ovarian suppression
OCP, Nuvaring, Patch
how do progestins treat endometriosis? example of pregestin
pseudo-pregnancy state- decrease estrogen & menstrual flow & reflux
oppose estrogen effects, converts estradiol to estrone
Depo shot, Mirena IUD
how do the SE of contraceptives compare with progestin?
a lot of similarities but with progestins theres higher breakthrough bleeding, edema and less weight gain
depo has delayed ovulation and fertility return
what are the 2nd line treatments for endometriosis?
GnRH agonist, antagonist
androgenic agent
combo antiestrogenic, antiprogesterone, androgenic agent
how does GnRH agonist treat endometriosis?
continuous treatment of GnRH causes downregulation and decreases steroidogenesis.
This stops LH/FSH release–> prevents ovulation–> pseudo menopause (estrogen levels similar to menopause levels)
common consequence of 2nd line treatments?
they have to use barrier contraceptive method
if GnRH agonist/antagonists stop ovulation, why do they need barrier contraceptives?
even though chances are small, taking GnRH increases chances of miscarriage or fetal abnormalities if pregnancy somehow occurred. OCP tend to increase estrogen they are working to reduce
what are some SE of GnRH meds
bone loss, hot flashes, mood swings
vaginal dryness, insomnia, decreased libido, depression
how do androgenic agents treat endometriosis? name one med
increases HDL, decreases LDL
its a testosterone derivative–> ATROPHY of endometrial implants
Danazol
what are some SE of Danazol & Gestrinone?
wt gain, muscle cramp, less breasts
oily skin, acne, sweating
hirsutism, voice deepening
how does combo pills treat endometriosis? name one med
decreases estrogen, progesterone and also androgenic
Gestrinone
when can you treat with CONSERVATIVE surgery?
if interested in pregnancy or in significant pain despite other tx
Laparoscopy vs Laparotomy
Laparoscopy is for mild to moderate disease; decreased adhesion formation
Laparotomy is for severe, deep infiltrating lesions; more invasive
Both are conservative surgeries
when can you treat w/ SEMIconservative surgery? examples?
long standing disease, uncontrollable pain, no concerns w/ fertility
hysterectomy and endometrial lesion removal
Conservative vs Semiconservative surgery
both can have recurrence
with semiconservative the time is longer till recurrence & could have surgical menopause
with conservative you can have repeat surgery
what can you do to avoid 2nd surgery?
combination treatment
surgery + hypoestrogenic treatment
this could increase pregnancy
how do you help someone with EARLY stage EM get pregnant?
surgery + supraovulation
what is supraovulation
ovarian stimulation so more than one egg gets released
how do you help someone with ADVANCED EM get pregnant?
3mo medical therapy THEN surgery + IVF
endometriosis vs adenomyosis pathology
w/ adenomyosis, endometrial tissue goes deeper to implant in myometrium!
what are sx of ademomyosis?
spasms
severe menorrhagia disabling dysmenorrhea
pelvic pain, painful intercourse
many are asymptomatic!
incidence of adenomyosis?
mainly in peri-menopausal; 20-30% of uteri
can also have endometriosis
possible PE findings for adenomyosis
high normal or enlarged globular uterus
diffuse of nodular
tender uterus
Pharm. Tx for symptomatic relief of adenomyosis
NSAIDs + OCP, GnRH agonist
Tx for people who have been pregnant before
uterine artery embolization could reduce symptoms
what is the only guaranteed treatment for adenomyosis
hysterectomy for symptomatic patients; preserve ovaries in younger patients!
why would you save the ovaries w/ hysterectomy in younger patients?
saving ovary is associated w/ lower risk of CHD and cancer related mortality
how does GnRH antagonists tx endometriosis?
inhbit GnRH receptors in pituitary–> decrease FSH/LH–> EST & PROG
need barrier contraceptive
