Endometriosis Flashcards
Incidence, in all/infertile/chronic pelvic pain
Later reproductive life 30-45 4-10% all repro women 20-25% infertile women 80% of those with chronic pelvic paiin
Infertility Pathology
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
Sites of endometriosis
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
Types (4)
Superficial
Deep infiltrating>5mm
Endometriomas
Adenomyosis
Symptoms
Infertility Disturbance of mensturation Pain Hematuria, dysuria Intestinal obstruction Acute abdomen Dyschezia Dysparaneuria Dysmenorrhea->not relieved by NSAIDs
Pathogenesis
- Retrograde mensturation
- Immunological theory
- Abnormal proliferation
- Direct spread
- 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)
Pain-cause, location, dysparaneuria
Pain--> congestive: lower back, pelvis at mensturation Ovulation pain mid cycles Dysparaneuria-->deep pelvis, pressure on uterosacral ligaments and rectovaginal septum in coitus
Physical examination
Single digit + bimanual examination
Pelvic mass (endometrioma)
Fixed and retroverted uterus
Utersacral nodularity, tenderness
Risk factors
Family history
Reproductive age group
Nulliparity
Mullerian anomalies
Weak: White Low BMI Autoimmune Late first sexual encounter Smoker Previous cesaerean
Investigations
TVUS->endometrioma
Diagnostic laparoscopy gold standard
Management
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
Does medical management improve fertility, laparoscopy, IVF as option
Medical-> not improved fertility
Laparoscopy improves
IVF not good option
What can be done at laparoscopy
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
When is lap indicated
In all infertile women ?
Benefits of laparoscopy
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
