Endometriosis

Question 1

Define endometriosis

Answer 1

Chronic inflammatory condition defined by endometrial stroma and glands found outside of the uterine cavity and in uterine musculature, commonly affecting the pelvic peritoneum and ovaries

Question 2

What are the risk factors for endometriosis

Answer 2

Reproductive age
FHx endometriosis
Nulliparity
Low BMI
Smoking
Previous caesarean delivery
Early menarche or late menopause

Question 3

What % of women of reproductive age have a degree of endometriosis

Answer 3

10%

Question 4

What are the symptoms of endometriosis

Answer 4

Secondary dysmenorrhoea
Chronic pelvic pain ± lower back pain
Deep dyspareunia
Subfertiliy
Dysuria, urgency, haematuria
Dyschezia

Question 5

What is the aetiology or endometriosis

Answer 5

Hormone mediated and associated with menstruation
Induces bleeding, chronic inflammation and scar tissue formation

Question 6

What are the differentials for endometriosis

Answer 6

Gynae: PID, ovarian cysts, ovarian cancer, pregnancy
Uterine: adenomyosis, primary dysmenorrhoea, pelvic congestion syndrome
Urological: cystitis, recurrent UTI
GI: IBS, gastroenteritis, coeliac disease

Question 7

What are the signs of endometriosis on examination

Answer 7

Abdominal exam
? Abdominal masses
Pelvic exam
Reduced organ mobility
Organ enlargement
Tender nodularity in the posterior vaginal fornix
Visible vaginal endometriotic lesions
Fixed, retroverted uterus (indicative of fibrosis and pelvic adhesions) → very tender, may not be able to examine

Question 8

What investigations are done for endometriosis

Answer 8

Clinical diagnosis is sufficient to commence treatment

bedside: Urine dip, urine pregnancy test, swab for STI
Imaging: TVUSS/TAUSS to detect endometrioma or uterosacral involvement (thickening)

Gold standard: laparoscopy

Question 9

What necessitates referral for women with endometriosis

Answer 9

? deep endometriosis involving bowel/bladder/ureter → refer to endometriosis centre

Severe, persistent or recurrent symptoms → gynae referral

Question 10

What is the management for endometriosis

Answer 10

1. Analgesia - NSAIDs, paracetamol (3 month trial)
2. COCP
3. POP or Mirena coil
4. GnRH analogues (induce pseudomenopause) e.g. leuprorelin
5. laparoscopic excision and laser treatment of endometrioma cysts
6. Hysterectomy (will not necessarily cure the symptoms)

+ follow up 3-6 months later

Question 11

What are the complications of endometriosis

Answer 11

Endometriomas (if the ovaries are affected) → these may rupture and can affect fertility by causing distortion of pelvic anatomy
Infertility
Adhesions
Bowel obstruction
Chronic pain
Reduced quality of life
Ovarian cancer

Question 12

What is the prognosis for endometriosis

Answer 12

Variable. May be a chronic disease affecting women throughout their reproductive lives
Majority of women: symptoms can be controlled with hormonal treatment, while others may have complex needs and require long-term support