Endometriosis

Question 1

Incidence, in all/infertile/chronic pelvic pain

Answer 1

Later reproductive life
30-45
4-10% all repro women
20-25% infertile women
80% of those with chronic
pelvic paiin

Question 2

Infertility Pathology

Answer 2

Infertility-->
ovulation in closed off area
damage to fimbrae
kinking of tubes by adhesions
blockage of tube by deposits of 
endometriosis in wall, embrotoxicity,
interfered normal ovulation/steroidogenesis

Question 3

Sites of endometriosis

Answer 3

Pelvis, ++uterosacral ligaments
and
\++ Ovaries (cysts)
Peritoneum-->adhesions
Bowel-->obstruction
Ureters/urethral-->hematuria,
dysuria
Bowel-->adhesions, obstruction
Uterine ligaments, tube,
rectouterine, pouch of douglas
Abdominal wall

Question 4

Types (4)

Answer 4

Superficial
Deep infiltrating>5mm
Endometriomas
Adenomyosis

Question 5

Symptoms

Answer 5

Infertility
Disturbance of mensturation
Pain
Hematuria, dysuria
Intestinal obstruction
Acute abdomen
Dyschezia
Dysparaneuria
Dysmenorrhea->not relieved by NSAIDs

Question 6

Pathogenesis

Answer 6

1. Retrograde mensturation
2. Immunological theory
3. Abnormal proliferation
4. Direct spread
5. Metaplasia

Emboli, totipotent cells
Failure of immune recognition
of emboli
Retrograde spread-->
– Menorrhagia
– Cervical stenosis
– Outflow tract obstruction

Portions of endometrium
outside–>cyclical changes,
+inflammation, fibrosis when
attaches to organs

– Endometrial type
glands
– Endometrial type
stroma
– Evidence of cyclical
activity (recent or old
blood)

Question 7

Pain-cause, location, dysparaneuria

Answer 7

Pain-->
congestive: lower back, pelvis at 
mensturation
Ovulation pain mid cycles
Dysparaneuria-->deep pelvis,
pressure on uterosacral ligaments
and rectovaginal septum in coitus

Question 8

Physical examination

Answer 8

Single digit + bimanual examination
Pelvic mass (endometrioma)
Fixed and retroverted uterus
Utersacral nodularity, tenderness

Question 9

Risk factors

Answer 9

Family history
Reproductive age group
Nulliparity
Mullerian anomalies

Weak:
White
Low BMI
Autoimmune
Late first sexual encounter
Smoker
Previous cesaerean

Question 10

Investigations

Answer 10

TVUS->endometrioma

Diagnostic laparoscopy gold standard

Question 11

Management

Answer 11

Fertility not desired:
NSAID + paracetamol
COCP is first line
-progestins, Mirena,
GnRH agonists (leuprorelin), 
danazol,
aromatase inhibitors?
1/3 no response,
may have SEs

If endometrioma->laparoscopy

If +for fertility:
Controlled ovarian hyperstimulation with lomiphene
Second line is IVF
Therapeutic laparoscopy

Question 12

Does medical management improve fertility, laparoscopy, IVF as option

Answer 12

Medical-> not improved fertility
Laparoscopy improves
IVF not good option

Question 13

What can be done at laparoscopy

Answer 13

Lap to ablate,-->
excise to leave less residual,
diathermy unstable (risk harm to
adjacents), ++pain releif
lyse adhesions, remove
endometriomas,
uterosacral nerve
ablation,
presacral neurectomy

Question 14

When is lap indicated

Answer 14

In all infertile women ?

Question 15

Benefits of laparoscopy

Answer 15

Higher pregnancy rate
Better long term prognosis
Early diagnosis allows more focused care
Diagnose and treat in one sitting
Quick recovery
Can stage the disease

Question 16

Pregnancy rate following treatment with laparoscopy

Answer 16

10-20%

Question 17

Classification of mild vs severe

Answer 17

Mild: no compromised fallopian tubes or ovaries
Severe: extensive adhesions, altered organ function

Question 18

Endometriosis and mood

Answer 18

+depression

Need to ask history of mood disturbance, look for evidence of depression