Endometriosis Flashcards

1
Q

What is endometriosis?

A
  • a condition in which there is ectopic endometrial tissue outside the uterus
  • endometrial tissue outside of the uterus is described as an endometrioma
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2
Q

What is adenomyosis?

A

endometrial tissue within the myometrium (muscle layer) of the uterus

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3
Q

What is a “chocolate cyst”?

A

used to describe endometriomas found in the ovaries

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4
Q

What is the main theory about the cause of endometriosis?

A

retrograde menstruation

  • during menstruation, the endometrial lining flows backwards
  • instead of passing through the cervix, it passes through the fallopian tubes and out into the pelvis + peritoneum

the exact cause of endometriosis is not known

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5
Q

What is the main presenting symptom of endometriosis?

A

cyclical pelvic pain

  • it is described as “dull” or “heavy”
  • during menstruation, the endometrial tissue throughout the body sheds and bleeds
  • this causes irritation / inflammation of the tissues around the sites of endometriosis
  • this causes pain that occurs during menstruation
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6
Q

What other type of pain can be associated with later stage endometriosis and why?

A
  • localised bleeding and inflammation can result in adhesions
  • this is the development of scar tissue that binds organs together
  • adhesions cause chronic, non-cyclical pain
  • this is “sharp”, “stabbing” or “pulling” and may be associated with nausea
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7
Q

How can endometriosis affect fertility?

A
  • it can result in reduced fertility in some women
  • this may be due to adhesions around the ovaries / fallopian tubes
  • they may block the release of eggs or narrow the tubes
  • endometriomas in the ovary may damage the eggs
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8
Q

What are the typical symptoms associated with endometriosis?

A
  • cyclical abdominal / pelvic pain
  • deep dyspareunia
  • dysmenorrhoea
  • infertility
  • endometriomas in the bladder / bowel may cause blood in the stool / urine during menstruation
  • there may be dyschezia / dysuria associated with menstruation

dyschezia = pain on defecation

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9
Q

What are the common sites that endometriomas may be found?

A
  • peritoneum
  • pouch of Douglas
  • ovary
  • fallopian tubes
  • ligaments
  • bladder
  • myometrium (adenomyosis)
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10
Q

Endometriosis at which site particularly causes deep dyspareunia?

A

pouch of Douglas

  • the posterior vaginal fornix is related to the pouch of Douglas
  • if there is an endometrioma in the pouch, it can be disturbed during penetration
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11
Q

What examinations would be performed in suspected endometriosis?

A
  • abdominal examination
  • speculum
  • bimanual examination (VE)
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12
Q

What might be seen during a speculum examination?

A
  • endometrial tissue may be visible in the vagina
  • particularly in the posterior fornix
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13
Q

What might be identified on bimanual examination?

A
  • a fixed cervix
  • a fixed, tender uterus (may be retroverted)
  • bilateral adnexal tenderness

  • fixed uterus is abnormal and suggests presence of scar tissue preventing its movement
  • the uterus should not be tender (sometimes after miscarriage / on period)
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14
Q

What investigations may be performed in endometriosis?

A
  • pelvic USS to identify large endometriomas
  • laparoscopy to visualise the endometriomas in the abdomen is the gold standard
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15
Q

What are the typical pelvic USS findings in endometriosis?

A
  • often, USS are unremarkable in endometriosis
  • large endometriomas and chocolate cysts can be visualised
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16
Q

Why is laparoscopy the gold standard for diagnosing endometriosis?

A
  • biopsies of any lesions can be taken
  • the surgeon is also able to remove deposits of endometriosis during the procedure to improve symptoms

if there are enough symptoms, a clinical diagnosis can sometimes be made without laparoscopy

17
Q

What are the 4 different management options for endometriosis?

A
  • analgesia (NSAIDs)
  • hormonal management with contraception
  • surgical management
  • hormonal management with GnRH analogues
18
Q

When is hormonal management with contraception offered?

A

this can be tried before establishing a definitive diagnosis with laparoscopy

laparoscopy may not be necessary if symptoms improve with treatment

19
Q

What are the options for hormonal management with contraception?

A
  • COCP (taken back-to-back for 4 months)
  • POP
  • Mirena coil
  • medroxyprogesterone acetate injection (Depo-Provera)
  • Nexplanon implant
20
Q

How does hormonal management with contraception work?

A
  • all methods cause ovarian suppression
  • they stop ovulation and reduce endometrial thickening
  • this reduces the incidence of cyclical pain
21
Q

What is the role of GnRH agonists in treatment of endometriosis?

A
  • they are used to induce a medical menopause
  • the cyclical pain tends to improve after the menopause when female sex hormones are reduced

e.g. goserelin or leuprorelin

22
Q

What are the adverse effects associated with GnRH agonists?

A
  • they produce symptoms of the menopause
  • e.g. hot flushes, night sweats + osteoporosis
23
Q

What are the surgical options for endometriosis?

A
  • laparoscopic ablation / excision of endometriotic spots
  • laparoscopic adhesiolysis to remove adhesions
  • laparoscopic cystectomy / oophorectomy
  • hysterectomy
24
Q

What is the main benefit of laparoscopic treatment?

A
  • it will improve symptoms and may also improve fertility
  • hormonal treatments will NOT improve fertility

fertility is improved in SOME women by treating adhesions and to return the anatomy to normal

25
Q

What is the final surgical option for endometriosis?

A

hysterectomy with bilateral salpingo-oopherectomy

  • as much of the endometriosis as possible is removed
  • this is NOT guaranteed to resolve symptoms
  • removal of the ovaries induces menopause and stops ectopic endometrial tissue from responding to the menstrual cycle