Endometriosis

Question 1

Typical symptoms of endometriosis

Answer 1

Dysmenorrhea, dyspareunia present in week preceding/during menses
Nodularity along back of uterus and uterosacral ligaments

DDx:
Adenomyosis would be associated with heavy periods and uterine enlargement, not normal periods
Fibromyalgia pain would not be confined to perimenstrual week

Question 2

Risk factors for endometriosis

Answer 2

Cervical stenosis - from prior cervical surgery (eg LEEP)

Question 3

Diagnosis of endometriosis

Answer 3

Exploratory surgery and biopsies are definitive

However, can initially treat based on clinical presentation alone

No imaging study or blood test

Question 4

What would you do for a patient with painful, heavy menses resistant to ibuprofen and OCPs?

Answer 4

Diagnostic laparoscopy for likely endometriosis or adhesions

Question 5

Endometriosis treatment

Answer 5

NSAIDs for pain
OCP (progestin suppresses endometrial tissue) without week of placebo pills
GnRH agonists (eg leuprolide, goserelin, nafarelin) - short-term only; side effects of menopausal symptoms, bone loss
Danazol - synthetic androgen with associated side effects

Surgical removal of implants/endometriomas - for those who fail medical treatment and/or are planning pregnancy in near future
Total hysterectomy/BSO (if not at young age)

Question 6

Echogenic, homogeneous ground-glass cyst of ovary

Answer 6

Endometrioma

DDx:
Serous cystadenoma and follicular cyst would be anechoic
Matura teratoma would be heterogeneous with calcification

Question 7

Which medication class for endometriosis has fastest onset of action?

Answer 7

GnRH antagonists (eg elagolix)

Question 8

What is norethindrone?

Answer 8

Synthetic progestin - suppresses endometrial growth but often takes >1 cycle for improvement in symptoms

Question 9

Common complication of endometriosis

Answer 9

Infertility - due to intraperitoneal inflammation and fibrosis; inflammation decreases sperm motility while adhesions distort pelvic anatomy and can cause tubal obstruction

Question 10

Endometriosis appearance on US

Answer 10

Homogenous cyst with internal echoes (ground glass)

Question 11

Why can a cornual/interstitial ectopic pregnancy lead to life-threatening hemorrhage?

Answer 11

Abundant blood supply from both uterine and ovarian vessels