Endometriosis

Question 1

define endometriosis

Answer 1

a benign condition in which endometrial glands and stroma are present outside the uterine cavity

Question 2

characteristic triad of sx

Answer 2

dysmenorrhea, dyspareunia, dyschezia

**amount of disease does not correlate with pt’s sx **

Question 3

what is the leading theory behind endometriosis?

Answer 3

Sampson’s Theory of Retrograde Menstruation (but no single theory explains all cases of endometriosis)

Question 4

Sampson’s Theory of risks associated with retrograde menstruation

Answer 4

• increased risk of endometriosis in women with cervical/vaginal atresia, or other outflow obstruction
• increased risk in women with early menarche, longer and heavier menstrual flow
• decreased risk in women with low estrogen levels

Question 5

familial association of endometriosis

Answer 5

if first degree relative affected, a pt has 7-10 fold increased risk of developing endometriosis

Question 6

how do you diagnose endometriosis?

Answer 6

tissue diagnosis from direct visualization with laparoscopy or laparotomy

Question 7

What CLASSIC findings of endometriosis may you see at time of laparoscopy?

Answer 7

black powder-burn lesions

Question 8

What NON-CLASSICAL findings of endometriosis may you see at time of laparoscopy?

Answer 8

red or white lesions

Question 9

What does an ovarian endometrioma look like on laparoscopy?

Answer 9

chocolate cyst

Question 10

Other areas of involvement of endometriosis?

Answer 10

can involve bladder and/or be deeply infiltrating of bowel and rectum

Question 11

What are common sites of endometriosis implants?

Answer 11

uterus, ovaries, uterosacral ligaments (but can be anywhere in peritoneal cavity or even chest cavity -but uncommon)

Question 12

what physical exam findings might make you suspect endometriosis?

Answer 12

Fixed, retroverted uterus.
Uterosacral ligament nodularity.
Palpable adnexal mass (endometrioma).

Question 13

Can you initiate medical trx if you suspect endometriosis, even without laparoscopy?

Answer 13

Yes. can start pt on trx. Pt should f/u in 3-6months to assess response. If no response, consider referral to GYN for diagnostic laparoscopy

Question 14

what are the pharmacological trx options for endometriosis?

Answer 14

NSAIDs, OCPs, lenorgestrel-containing IUD, progestins (DMPA/depo provera, or norethindrone acetate), GnRH agonsists (DepoLupron)**, Danazol (uncommon; androgen)

Question 15

What is the use for GnRH agonists in endometriosis? Example of a GnRH agonist?

Answer 15

Causes chemical menopause. Leuprolide (Lupron)

Question 16

Side effects of GnRH agonist?

Answer 16

hot flashes, vaginal dryness, osteopenia(reversible with short term use)

Question 17

How do you prescribe a GnRH agonist for endometriosis?

Answer 17

start with short duration trx (6 months). If pt is satisfied with trx and sx are under control, then may continue for more than 6 months with “add back” therapy

Question 18

What is included with endometriosis “add-back” therapy?

Answer 18

• norethindrone acetate 5mg/d
• conjugated estrogen 0.625 mg/d with medroxyprogesterone acetate 2.5mg/d.
• transdermal estradiol 25 mcg/d with medroxyprogesterone acetate 2.5 mg/d.1

Question 19

Goals of surgical trx for endometriosis?

Answer 19

definitive dx, remove implants and prevent progression, relieve pain, enhance fertility

Question 20

what guides the surgical trx offered to pts with endometriosis?

Answer 20

desire for future fertility

Question 21

What surgical trx is offered to pts with endometriosis who desire future fertility?

Answer 21

• laparoscopic or open surgery to destroy all endometriotic implants and remove all adhesive disease
• removal of all endometriomas >3cm is recommended, via excision (drainage = high recurrence rate)

Question 22

What surgical trx is offered to pts with endometriosis who do NOT desire future fertility?

Answer 22

• the most comprehensive surgery includes hysterectomy, bilateral salpingo-oophorectomy, and destruction/removal of all enodmetriotic disease
• pt will experience the same sx as if put in chemical menopause
• some pts may still require medical suppression bc some cells may remain

Question 23

Preoperative rationale for medication component of combination therapy

Answer 23

• assist at time of surgery by decreasing volume and vascularity of endometriotic implants
• trx microscopic dz
• ?avoid? therapy in postop period when chance for conception should be increased

Question 24

Postoperative rationale for medication component of combination therapy

Answer 24

• trx microscopic dz
• avoid extensive peritoneal injury and bleeding, thus decreasing adhesion formation in future
• reduce symptomatic recurrences