Endometriosis

Question 1

Definition

Answer 1

Where endometrium-like tissue grows outside of the uterine cavity.

Question 2

Where can this ectopic tissue grow in

Answer 2

• Fallopian tubes
• Ovaries
• Rectovaginal pouch
• Uterosacral ligaments
• Pelvic peritoneum
• Lateral pelvic walls
• Extra-pelvic deposits: found in bowel or pleural cavity, (rare)

Question 3

Epidemiology

Answer 3

• Age: 20-40
• Nulliparity: women who have not given birth
• Early menarche
• Late menopause
• Vaginal outflow obstruction
• Family history
• Low BMI
• Smoking
• White ethnicity

Question 4

Signs

Answer 4

Bimanal examination:
- Generalised tenderness
- Reduced organ mobility
- Palpable and tender uterosacral ligament nodules
- Tender nodularity in the posterior vaginal fornix
- Visible vaginal endometriotic lesions may be seen

Question 5

Symptoms

Answer 5

• Chronic pelvic pain (>6 months): cyclical or continuous
• Period-related pain (dysmenorrhoea)
• Heavy periods (menorrhagia)
• Deep dyspareunia
• Subfertility
• Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)

Question 6

Diagnosis

Answer 6

GOLD STANDARD: Diagnostic laparoscopy
Transvaginal ultrasound (TVUS)
Vaginal swabs: screen for chlamydia and gonorrhoea if PID suspected

Question 7

Treatment

Answer 7

• FIRST LINE = Analgesia: consider short trial of para or NSAID
• Second line:
  = Oral contraception: the COCP or progestogen-only pill reduces menstruation and thus Sx
  = Intrauterine system (IUS): levonorgestrel-releasing coils (e.g. Mirena) can reduce endometriosis-related pain
  = Do not offer hormonal treatment to women trying to conceive

Question 8

When should Px be referred to secondary care

Answer 8

• Women with persistent or severe symptoms
• Women with pelvic signs of endometriosis
• If initial management is ineffective or contraindicated

Question 9

Secondary care options

Answer 9

• Surgical management: laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception.
  = Ovarian cystectomy (for endometriomas) is also recommended
  = Hysterectomy in severe, refractory cases
• GnRH analogues: these agonists (e.g. leuprorelin acetate) can prevent FSH/LH release, inducing a ‘pseudomenopause’, and should be considered as an adjunct pre-surgery

Question 10

Complications

Answer 10

• Endometriomas: also known as “chocolate cysts”. This can lead to rupture of ovarian cysts, as well as subfertility
• Subfertility
• Adhesions: fibrotic bands may form in the abdominal or pelvic cavity secondary to endometriosis or laparoscopy, increasing the risk of bowel obstruction
• Chronic pain
• Depression and anxiety