Endometriosis

Question 1

What is this?

What are some of the theories of its aetiology?

What’s its prognosis?

Answer 1

➊ Ectopic endometrial tissue outside the uterus

➋ • Retrograde menstruation where endometrial lining flows backwards through fallopian tubes into pelvis and peritoneum
• Embryonic cells remain outside uterus and develop in endometrial tissue later
• Lymphatic spread of endometrial cells
• Metaplastic change

➌ Tends to resolve after menopause due to its relation to the hormonal cycle

Question 2

What’s its main presenting symptom?
→ Why does this occur?
→ What can this lead to?

How else does can it present?

What may be found O/E?

Answer 2

➊ Cyclical pain (Dysmenorrhoea)
→ The ectopic endometrial cells respond to hormones as normal, so, during menstruation, it’ll also shed its lining and bleed. This causes irritation and inflammation, therefore resulting in this cyclical, dull, heavy/burning pain during menstruation.
→ Adhesions, which can cause infertility and chronic, non-cyclical pain (sharp/shooting/pulling)

➋ • Deep dyspareunia
• Infertility – The localised inflammation can lead to adhesions, which may form around the ovaries and fallopian tubes
• Bowel or urinary symptoms – May be endometrial deposits in bladder or bowel, leading to cyclical haematuria or pr bleeding

➌ • Endometrial tissue visible in vagina (if very severe)
• Fixed cervix on bimanual exam
• Tenderness

Question 3

Which investigations should be done?

Answer 3

• TVUS – Often normal
• Diagnostic laparoscopy – Gold standard way of diagnosing, as well as allowing for removal of the deposits

Question 4

Management:
What is given 1st line?

What are the hormonal options?
→ How does this affect fertility?

What are the surgical option?
→ How does this affect fertility?

Answer 4

➊ Paracetamol/NSAIDs

➋ COCP, Progestogen (e.g. POP) Mirena coil (i.e. IUS)
→ Improves symptoms, but not fertility

➌ Excision/Ablation, or Hysterectomy
→ Possibility of improving fertility, but may cause scarring