Endometriosis

Question 1

What is endometriosis?

Answer 1

Endometriosis is a chronic condition in which endometrial tissue is located at sites other than the uterine cavity. It can occur in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs.

Around 2 million women in the UK are affected, with most diagnoses made between the ages 25 and 40.

Question 2

proposed pathology of endometriosis?

Answer 2

The exact pathophysiology of endometriosis is unclear. One proposed theory is retrograde menstruation. This is where the endometrial cells travel backwards from the uterine cavity, through the Fallopian tubes, and deposit on pelvic organs – where they can seed and grow. It has also been suggested that these cells may also be able to travel to distant sites through the lymphatic system and vasculature.

As endometrial tissue is sensitive to oestrogen, the symptomatology is dependent on the individual’s menstrual cycle. As with uterine endometrial tissue, women will have bleeding from the ectopic tissue during menstruation – resulting in pain and bloating/distension at the ectopic sites. Repeated inflammation and scarring can also occur leading to adhesions. During pregnancy and menopause, symptoms will be reduced.

Question 3

What are the clinical features of endometriosis?

Answer 3

The most common presenting symptom of endometriosis is cyclical pelvic pain, which occurs at time of menstruation. In cases where adhesions have formed, the pain may be constant.

Other symptoms include dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficult, painful defecating), and subfertility.

Those with endometriosis at distant sites may experience focal symptoms of bleeding. For example, ectopic endometrial tissue in the lungs may produce features of haemothorax at the time of menstruation.

On bimanual examination, the clinician may note:

A fixed, retroverted uterus
Uterosacral ligament nodules
General tenderness
Note: An enlarged, tender and boggy uterus is indicative of adenomyosis

Question 4

What might you find on examination in endometriosis?

Answer 4

• Fixed retroverted uterus
• Pelvic tenderness
• Tender utero-sacral ligaments * Enlarged ovaries
• Palpable nodules in Pouch of Douglas and utero-sacral ligaments

Question 5

What is your DDx in endometriosis?

Answer 5

It is important to rule out the following differentials which also present with similar features:

Pelvic Inflammatory Disease: This can present with dyspareunia, pelvic pain and abnormal and/or heavy bleeding.
Ectopic pregnancy: This can present with dyspareunia, pelvic pain and abnormal and/or heavy bleeding, and sometimes collapse.
Fibroids: This can present with pelvic pain, long duration of menstrual bleedings, heavy menstrual bleeding, a feeling of a mass or bloating.
Irritable Bowel Syndrome: abdominal pain, dyspareunia and bloating.

Question 6

How do you investigate for endometriosis?

Answer 6

Gold standard = Laparoscopy ***

might find;
Chocolate cysts
Adhesions
Peritoneal deposits

Powder burn lesions
* Gunshot lesions
* Red implants
* Black-bluish lesions
* Nodules or cysts
* Endometriomas - chocolate cysts, kissing ovaries

Question 7

How do you manage endometriosis?

Answer 7

Medical– suppress ovarian function
* NSAIDs
* Progestogens
* COCP
* GnRH analogues - Decapeptyl
* Danazol (oral androgen)
* Gestrinone
* Medroxyprogesterone acetate – long-term
* Mirena

+ pain mgmt

Surgical
* Conservative – excision, ablation
* Placebo effect of laparoscopy
* TAH and BSO if family complete
Complementary
* TENS, acupuncture, vitamin B1, magnesium, Chinese medicine, homeopathy