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OBGYN > Endometriosis > Flashcards

Endometriosis Flashcards

1
Q

What is endometriosis?

A

Presence of endometrial like tissue outside of the uterus, which induces a chronic inflammatory response

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2
Q

What is the epidemiology of endometriosis?

A
  • prevalence difficult as diagnosis traditionally requires laparoscopic confirmation
  • 1-2% diagnosed
  • overall estimated 2-10% of general female population
  • but up to 50% of infertile women
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3
Q

Who is endometriosis more common in? (4)

A
  • nullipaous women/ low parity
  • age 30-45yrs
  • first degree relative
  • geographic variation (japan)
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4
Q

What are the theories behind the etiology of endometriosis?

A

ITEM

  • Implantation (most currently accepted theory)
  • pelvis: retrograde menstruation (genetic and immunological factors might be present as retrograde menstruation is common)
  • Transformation: metaplasia of coelomic cells
  • Embolisation: lymphatic or blood borne spread
  • Mechanical transplantation (eg endometriosis in c-section scars or episiotomy wounds)
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5
Q

What is the pathology of endometriosis?

A

Oestrogen dependent

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6
Q

What does endometriosis being Oestrogen dependent mean for its course?

A

Regresses in pregnancy and menopause

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7
Q

Where can endometriosis be found?

A

Ovaries>posterior leaf of broad ligament> pouch of douglas (vesicorectal pouch in women)> uterosacral ligament> rectum, urinary tract, lungs
Also cervix, vagina, umbilicus, abdo wound scars. Undersurface of diaphragm

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8
Q

What pathology is seen in endometriosis?

A
  • endometriotic ‘lesions’ cause chronic inflammatory response
  • fibrosis
  • adhesions
  • ‘frozen pelvis’
  • endometriomas/chocolate cyst
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9
Q

What is a ‘frozen pelvis’?

A

Think retroverted fixed pelvis (also seen in PID)

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10
Q

What are two important things to remember when taking a history of a woman with suspected endometriosis?

A
  • extremely variable symptoms (or absent) and overlap with other conditions
  • symptoms severity correlates poorly with findings on laparoscopy
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11
Q

What are the symptoms of endometriosis seen in the clinical history?

A
  • Pain
    Pelvic:
  • most predictive symptoms are secondary dysmenorrhea (uni or bilateral) and deep dyspareunia
  • other pelvic pain = post-menstrual, throughout cycle
  • acute pelvic pain = rupture/torsion chocolate cyst
  • other sites of pain = dyschezia, dysuria (usually cyclical)
  • bleeding:
  • occasionally menstrual problems (menorrhagia, IMB)
  • haematochezia, haematuria, haemoptysis (cyclical)
  • Dyschezia = pain passing bowel motion
    Dysuria = pain passing urine
    Dyschezia and dysuria are cyclical ie around the period
  • infertility
  • obstruction: GI/ureters (with depp infiltrating endometriosis)
  • fatigue
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12
Q

What are considered deep endometriosis lesions?

A

> 3cm depth of invasion

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13
Q

What symptoms may a woman with endometriosis have relating to the female reproductive tract? (6)

A
  • dysmenorrhea (spasmodic and severe)
  • lower abdo and pelvic pain
  • dyspareunia
  • rupture/torsion of endometrioma (cyst accident)
  • occasionally menstrual problems
  • infertility
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14
Q

What symptoms may a woman with endometriosis have relating to the urinary tract? (3)

A
  • cyclical dysuria
  • cyclical Haematuria
  • ureteric obstruction
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15
Q

What symptoms may a woman with endometriosis have relating to the GI tract? (3)

A
  • dyschezia
  • cyclical rectal bleeding
  • obstruction
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16
Q

What symptoms may a woman with endometriosis have relating to surgical scars/ umbilicus? (2)

A

Cyclical pain and bleeding

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17
Q

What symptoms may a woman with endometriosis have relating to the lungs? (2)

A
  • cyclical haemoptysis
  • haemopneumothorax
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18
Q

What clinical findings are seen on examination in endometriosis?

A
  • abdomen: tenderness or possible mass
  • on vaginal exam:
  • if mild: nil abnormal
  • see next few slides
  • on speculum:
  • visible lesions on vagina or cervix
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19
Q

What examination findings are seen in the pouch of Douglas? (2)

A
  • tenderness behind uterus
  • possible thickness or palpable nodule (uterosacral ligaments)
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20
Q

What examination findings are seen in the adnexa in endometriosis?

A
  • enlarged ovaries (endometrioma) or tenderness
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21
Q

What examination findings are seen in the uterus in endometriosis?

A
  • if severe fixed retroverted uterus (adhesions)
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22
Q

What investigations would you use to stage endometriosis and is traditionally the gold standard?

A

Laparoscopy and visualisation + biopsy for histology

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23
Q

What grading system can be used to grade endometriosis based on laparoscopy findings?

A

AFS grading system:
* stage 1 = minimal
* stage 2 = mild
* stage 3 = moderate
* stage 4 = severe
* stages poorly reflect the severity of symptoms

24
Q

What do the ESHRE guidelines recommend for endometriosis investigations?

A

ESHRE guidelines 2022 recommend a move away from laparoscopy as gold standard and to use in cases of negative imaging results and/or when empirical treatment is unsuccessful or inappropriate.

ESHRE guidelines advise TVUS and MRI have a better sensitivity/specificity for ovarian/deep endometriosis but not for superficial endometriosis.

25
Q

How is ultrasound used to investigate for endometriosis?

A

TVUS (will not show small lesions, but will show ovarian endometrioma and possible deep infiltrating endometriosis)

26
Q

How is MRI used to investigate for endometriosis?

A

Adenomyosis + peritoneal lesions

Assess the extent of deep infiltrating disease including bowel and bladder

27
Q

What other tests can be done to investigate for endometriosis?

A
  • consider: IVP/CT urogram/cystoscopy or barium studies (UG or GI involvement)
  • CA125 sometimes raised - ESHRE recommends not to use as bio marker but to be aware endometriosis may increase level
28
Q

At what level is CA125 considered abnormal?

A

> 35IU

29
Q

What are the complications of laparoscopy?

A
  • anaesthetic risk
  • damage to local structures (eg bowel, bladder, pelvic vessels: 1:1000)
  • CO2 embolism
  • infection (very rare), bleeding, pain
  • need to convert to laparotomy
30
Q

What are the findings at laparoscopy in the case of endometriosis?

A

Active lesion = red dots
Older less active lesions = black dots
Overtime can get the scarring and with the inflammation can get neovascularizatoin
Classical lession = white scar with black dots in the middle
Atypical = clear vesicles
Can see endometrioma

Taken from impey: red vesicles or dots: active endometriosis. Black powder burn dots or white scarring less active.
Extensive adhesions (due to progressive fibrosis) or endometrioma (chocolate cyst – due to altered blood) is severe disease. In most severe cases – frozen pelvis due to adhesions

31
Q

What are some of the pathologies seen in endometriosis?

A
32
Q

What complications of endometriosis can be seen on laparoscopy?

A
33
Q

Does asymptomatic endometriosis require treatment?

A

No - except perhaps endometriomas

34
Q

What does the treatment of endometriosis depend on?

A

Depends on whether main problem is:
* dysmenorrhea = medical treatment (usually at least 6 months) or surgical
* subfertilty: surgical treatment better

Will regress or not progress in 50%

35
Q

What is the medical management of endometriosis?

A
  • analgesics:
  • NSAIDS (eg mefenamic acid - Ponstan)
    +/- paracetamol
    +/- opiates
  • hormonal treatment: mimic pregnancy or menopause or androgens
36
Q

What hormonal treatment is used for endometriosis?

A
  • COC
  • progestogens (high dose): MPA, norethisterone, Mirena
  • GnRH analogues
37
Q

How does the COC work to treat endometriosis?

A
  • decrease dysmenorrhea and blood loss
  • often back to back or tricyclics
38
Q

What is MPA that is used to treat endometriosis?

A

Depo injection 3 monthly

39
Q

What is norethisterone that is used to treat endometriosis?

A

Old mini pill

40
Q

How do GnRH analogues work to treat endometriosis?

A

Induce a temporary menopausal state

41
Q

What are the issues with GnRH analogues in the treatment of endometriosis?

A

S/e similar to menopause so eg hot flushes and night sweats

42
Q

How do GnRH analogues work to treat endometriosis?

A

GnRH analogue given at a higher sustained dose (ie not pulsatile as with normal GnRH) causes down regulation of the pituitary receptors which leads to reduced FSH/LH and estrogen = medically induced menopause

43
Q

What 3 conditions can GnRH analogues be used to treat?

A
  • endometriosis
  • menorrhagia
  • fibroids
44
Q

How are GnRH analogues given in the treatment of endometriosis?

A

BMD: 5% in 6/12

Add back HRT to allow you to give it for up to 2 years

45
Q

What other hormonal treatment class is an option for endometriosis?

A

Synthetic compounds with androgenic effects

46
Q

What are 2 examples of synthetic compounds with androgenic effects used to treat endometriosis?

A
  • Danazol (daily)
  • Gestrinone (twice weekly)
47
Q

How do synthetic compounds with androgenic effects used to treat endometriosis work?

A

ovarian suppression

48
Q

Why are these synthetic compounds like Danazol and Gestrinone seldom now used and no longer mentioned in the NICE guidelines?

A

Androgenic side effects = weight gain, greasy skin, acne

Long term = LFTs and lipid abnormalities

49
Q

What surgical treatment can be used to treat endometriosis?

A

Laparoscopy: scissors/laser/diathermy destruction of endometriotic lesions

50
Q

How effective is surgical treatment for endometriosis?

A

70% have symptomatic improvement

+/- improve conception rates (preferable if pain + fertile issues)

51
Q

How can the adhesions endometriosis causes be managed?

A

Dissection of adhesions

52
Q

How can endometriomas be managed surgically?

A

Removal - stripping associated with better conception rates and less reoccurrence than ablation

Endometrioma - drain the blood and then remove the wall of the cyst so less likely to reform

53
Q

What surgery is the last resort for endometriosis?

A

Hysterectomy in severe cases (completed family)
- HRT if remove ovaries, may defer for 6/12
- combined HRT (not oestrogen alone)

Ovaries produce estrogen so strong case for removal of ovaries
Not Estrogen alone as risk of endometrial cancer in the lesions of endometriosis

54
Q

How does endometriosis impact fertility?

A
  • 30-40% of couples with endometriosis complain of difficulty conceiving
  • easy to explain in severe cases, harder in mild endometriosis
  • Cochrane 2014 suggests laparoscopic removal of deposits may improve fertility
  • Drainage and stripping (not ablation) of chocolate cysts improves fertility
  • Severe disease involving tubes may require IVF.
55
Q

What are the DDx pelvic pain and deep dyspareunia? (6)

A
  • endometriosis
  • PID
  • ovarian mass
  • IBS
  • psychosexual causes
  • musculoskeletal pain
56
Q

What emotional support would you give for someone with endometriosis?

A

Endometriosis can be a long-term condition with significant physical, psychological, sexual and social impact.

Consider support services e.g.
Endometriosis Association of Ireland

57
Q

A 31y/o woman presents to your clinic with a 12 months history of pelvic pain and deep dyspareunia.
A) What factors would you look for in the history if you suspect endometriosis?
B) What investigations would you do?
C) How can you treat endometriosis?
D) She has been trying to get pregnant for 2 years and asks it this problem is related and what can be done?

A

OBGYN (25 decks)

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