Endometriosis

Question 1

menstruation is triggered by fall in what hormone 2 weeks after ovulation if not pregnant

Answer 1

progesterone

Question 2

what is endometriosis

Answer 2

growth of ectopic endometrial tissue outside of the uterine cavity most commonly in the pelvic peritoneum and the ovaries

Question 3

what are the symptoms of endometriosis

Answer 3

1. chronic pelvic pain or cyclic pelvic pain
2. secondary dysmenorrhoea - pain often starts days before bleeding.
3. deep dyspareunia
   4.non-gyne symptoms; dysuria, haematuria, dyschezia, haemochezia are far less common
4. sub fertility
5. pain impacting QoL and normal function

Question 4

what population usually gets endomeriosis

Answer 4

women of reproductive age
positive family history
nulliparity more likely

Question 5

What may be found on clinical examination in a woman with endometriosis (pelvic examination or abdominal)

Answer 5

abdominal masses
reduced uterus mobility
uterus enlargement
tender nodularity in posterior vaginal fornix
visible vaginal endometriotic lesions

Question 6

When would you perform TV USS in the diagnosis of endometriosis

Answer 6

to confirm diagnosis.
to identify endometriomas and endometriosis involving the bowel, bladder, or uterus.

Question 7

When would you consider diagnostic laparoscopy in the management of endometriosis

Answer 7

1. Consider laparoscopy to diagnose endometriosis in women with suspected endometriosis, even if the ultrasound was normal.
2. For women with suspected deep endometriosis involving the bowel, bladder or ureter, consider a pelvic ultrasound or MRI before an operative laparoscopy.

If a full, systematic laparoscopy is performed and is normal, explain to the woman that she does not have endometriosis, and offer alternative management.

Question 8

There is poor correlation between laparoscopic findings and severity of symptoms, true or false?

Answer 8

true

Question 9

what is an endometrioma

Answer 9

a lump of endometrial tissue that is outside the uterus

Question 10

what is an adenomyosis

Answer 10

a lump of endometrial tissue within the myometrium of the uterus.

Question 11

what is the likely pathophysiology of chronic non cyclical pain in endometriosis

Answer 11

Localised bleeding and inflammation can lead to adhesions. Inflammation causes damage and development of scar tissue that binds the organs together. For example, the ovaries may be fixed to the peritoneum, or the uterus may be fixed to the bowel. Adhesions can also occur after abdominal surgery. Adhesions lead to a chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with nausea.

Question 12

Does a normal USS exclude a diagnosis of endometriosis?

Answer 12

No, USS are often unremarkable in patients with endometriosis. Patients where clinical suspicion is strong should be referred to gyne for a laparoscopy with biopsy (gold standard)

laparoscopy has the added benefit of the potential to remove endometrial deposits and potentially improve symptoms.

Question 13

What is first line analgesia in endometriosis

Answer 13

NSAID and paracetamol

Question 14

what are hormonal options in the management of endometriosis

Answer 14

COCP - can be used back to back without a pill free period.
POP.
Depo injection.
Nexplanon implant.
Mirena coil.
GnRH agonists - specialist

hormonal treatments may improve symptoms but will not improve fertility

Question 15

What are surgical options in the management of endometriosis

Answer 15

laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions

hysterectomy and bilateral salpingo-opherectomy * removing the ovaries will cause menopause.

laparoscopic treatment may improve fertility.

Question 16

what management approach is usually most suitable for cyclical pain

Answer 16

hormonal medications that stop ovulation and reduce endometrial thickening. E.g COCP, POP, depot injection, progestin implant, Mirena coil.

Question 17

what is a second line option to treat cyclical pain in endometriosis bar contraceptives

Answer 17

GnRH e.g goserelin. The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore treatment another treatment option for endometriosis is to induce a menopause like state using GnRH.
They shut down the ovaries temporarily and can be useful in treating pain in may women. However inducing the menopause has SE e.g hot flushes, night sweats, risk of osteoporosis.

Question 18

what is the best approach to try to improve fertility in endometriosis

Answer 18

surgery to try to remove as much of the endometriosis as possible, treat any adhesions and return the anatomy to normal. This improves fertility in some woman but not all.