Endometriosis Flashcards
What is endometriosis?
- a condition in which there is ectopic endometrial tissue outside the uterus
- endometrial tissue outside of the uterus is described as an endometrioma
What is adenomyosis?
endometrial tissue within the myometrium (muscle layer) of the uterus
What is a “chocolate cyst”?
used to describe endometriomas found in the ovaries
What is the main theory about the cause of endometriosis?
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
What is the main presenting symptom of endometriosis?
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
What other type of pain can be associated with later stage endometriosis and why?
- 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
How can endometriosis affect fertility?
- 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
What are the typical symptoms associated with endometriosis?
- 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
What are the common sites that endometriomas may be found?
- peritoneum
- pouch of Douglas
- ovary
- fallopian tubes
- ligaments
- bladder
- myometrium (adenomyosis)
Endometriosis at which site particularly causes deep dyspareunia?
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
What examinations would be performed in suspected endometriosis?
- abdominal examination
- speculum
- bimanual examination (VE)
What might be seen during a speculum examination?
- endometrial tissue may be visible in the vagina
- particularly in the posterior fornix
What might be identified on bimanual examination?
- 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)
What investigations may be performed in endometriosis?
- pelvic USS to identify large endometriomas
- laparoscopy to visualise the endometriomas in the abdomen is the gold standard
What are the typical pelvic USS findings in endometriosis?
- often, USS are unremarkable in endometriosis
- large endometriomas and chocolate cysts can be visualised
Why is laparoscopy the gold standard for diagnosing endometriosis?
- 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
What are the 4 different management options for endometriosis?
- analgesia (NSAIDs)
- hormonal management with contraception
- surgical management
- hormonal management with GnRH analogues
When is hormonal management with contraception offered?
this can be tried before establishing a definitive diagnosis with laparoscopy
laparoscopy may not be necessary if symptoms improve with treatment
What are the options for hormonal management with contraception?
- COCP (taken back-to-back for 4 months)
- POP
- Mirena coil
- medroxyprogesterone acetate injection (Depo-Provera)
- Nexplanon implant
How does hormonal management with contraception work?
- all methods cause ovarian suppression
- they stop ovulation and reduce endometrial thickening
- this reduces the incidence of cyclical pain
What is the role of GnRH agonists in treatment of endometriosis?
- 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
What are the adverse effects associated with GnRH agonists?
- they produce symptoms of the menopause
- e.g. hot flushes, night sweats + osteoporosis
What are the surgical options for endometriosis?
- laparoscopic ablation / excision of endometriotic spots
- laparoscopic adhesiolysis to remove adhesions
- laparoscopic cystectomy / oophorectomy
- hysterectomy
What is the main benefit of laparoscopic treatment?
- 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
