Endometriosis Flashcards
define endometriosis
a benign condition in which endometrial glands and stroma are present outside the uterine cavity
characteristic triad of sx
dysmenorrhea, dyspareunia, dyschezia
**amount of disease does not correlate with pt’s sx **
what is the leading theory behind endometriosis?
Sampson’s Theory of Retrograde Menstruation (but no single theory explains all cases of endometriosis)
Sampson’s Theory of risks associated with retrograde menstruation
- 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
familial association of endometriosis
if first degree relative affected, a pt has 7-10 fold increased risk of developing endometriosis
how do you diagnose endometriosis?
tissue diagnosis from direct visualization with laparoscopy or laparotomy
What CLASSIC findings of endometriosis may you see at time of laparoscopy?
black powder-burn lesions
What NON-CLASSICAL findings of endometriosis may you see at time of laparoscopy?
red or white lesions
What does an ovarian endometrioma look like on laparoscopy?
chocolate cyst
Other areas of involvement of endometriosis?
can involve bladder and/or be deeply infiltrating of bowel and rectum
What are common sites of endometriosis implants?
uterus, ovaries, uterosacral ligaments (but can be anywhere in peritoneal cavity or even chest cavity -but uncommon)
what physical exam findings might make you suspect endometriosis?
Fixed, retroverted uterus.
Uterosacral ligament nodularity.
Palpable adnexal mass (endometrioma).
Can you initiate medical trx if you suspect endometriosis, even without laparoscopy?
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
what are the pharmacological trx options for endometriosis?
NSAIDs, OCPs, lenorgestrel-containing IUD, progestins (DMPA/depo provera, or norethindrone acetate), GnRH agonsists (DepoLupron)**, Danazol (uncommon; androgen)
What is the use for GnRH agonists in endometriosis? Example of a GnRH agonist?
Causes chemical menopause. Leuprolide (Lupron)
Side effects of GnRH agonist?
hot flashes, vaginal dryness, osteopenia(reversible with short term use)
How do you prescribe a GnRH agonist for endometriosis?
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
What is included with endometriosis “add-back” therapy?
- 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
Goals of surgical trx for endometriosis?
definitive dx, remove implants and prevent progression, relieve pain, enhance fertility
what guides the surgical trx offered to pts with endometriosis?
desire for future fertility
What surgical trx is offered to pts with endometriosis who desire future fertility?
- 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)
What surgical trx is offered to pts with endometriosis who do NOT desire future fertility?
- 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
Preoperative rationale for medication component of combination therapy
- 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
Postoperative rationale for medication component of combination therapy
- trx microscopic dz
- avoid extensive peritoneal injury and bleeding, thus decreasing adhesion formation in future
- reduce symptomatic recurrences
