Endometriosis Flashcards
What is endometriosis?
It is the growth of endometrial tissue outside of the uterus.
It commonly grows in the pelvis:
- Pouch of douglas
- Uterosacral ligaments
- Ovarian fossa
- Bladder
- Peritoneum
Rarely can grow in other areas of the body:
- Lung
- Brain
- Muscle
How common is endometriosis and what is the common age range in which women suffer from it?
Common 10-15% of women of reproductive age (many are asymptomatic)
Most commonly occurs in 30-45yo women.
What are the complications of endometriosis?
Endometrioma (chocolate cyst):
This is where accumulated blood forms a cyst in the ovaries.
Fibrosis and adehsions:
Causes inflammation and in turn fibrosis and adhesions which can cause infertility.
DIE (deep infiltrating endometriosis):
Endometriosis which produces its own oestrogen by converting androgens. Makes it very difficult to treat.
Increases risks of: Breast Ca, low grade endometrial and ovarian Ca, IBS
How does endometriosis occur?
Aetiology is not known but it is thought to be due to retrograde menstruation.
Aka endometrium flows backwards through the fallopian tubes and into the abdomen where it imbeds itself and grows.
What are the risk factors for endometriosis?
It is related to oestrogen levels and menstruation.
Aka increased oestrogen and menstruation = increased risk
RF:
- Early menarche
- Late menopause
- Long menstrual flow
- Short cycles (= increased no of cycles)
- Nulliparous
- FH as there is thought to be a genetic link
What are the signs and symptoms of endometriosis?
May be asymptomatic.
Symptoms:
- Cyclic pelvic pain
- Secondary dysmenorrhoea (with menstruation pain maximal at time of maximal flow)
- Dyspareunia
- Dysuria
- Dyschezia (difficulty defecating)
Infertility due to anatomical distortion of the pelvic architecture.
Note: Severity of the pain does not relate to the severity f the disease.
How should you investigate a patient describing cyclic pelvic pain, dyspareunia and dysuria?
Bedside:
Urinalysis (rule out UTI)
Pregnancy test (any women of child bearing age)
Vaginal swabs (STI)
Bloods:
FBC (rule out infection)
Imaging:
Transvaginal US as if present an ovarian endometrioma can be visualised.
MRI +/- intravenous pyelogram shows presence of DIE, ureteric, bladder and bowel involvement.
Invasive:
Laparoscopy and biopsy (gold standard) the diagnosis is only made with certainty after visualisation and biopsy.
On laparoscopy of a patient with endometriosis what indicates active, less active and severe disease?
Active disease:
Red vesicles or punctate (indent) marks on the peritoneum.
Less active disease:
White scars or brown spots (powder burn spots)
Severe disease:
Characterised by extensive adhesions and endometriomas
What is the aim in medical and surgical management of endometriosis?
Only treat symptomatic patients (fertility issues are consider as a symptom)
Medical: goal is to suppress ovulation and induce amenorrhoea. This does not eradicate lesions but controls symptoms.
Surgical: aim is to remove endometriotic lesions to remove the disease, radical surgery also aims to remove adhesions to improve fertility.
Describe the different options of medical treatment?
Analgesia:
Ibuprofen –> cyclical pain
Mefenamic acid –> dysmenorrhoea or menorrhagia
Tranexamic acid (anti fibrinolytic) –> menorrhagia
Hormonal (stop ovulation = stop pain)
- COCP
- POP
- GnRH (causes low oestrogen levels stopping thickening of the endometrium and eventual menstruation which causes pain)
Note: GnRh is only license for 6 months use as it can cause side effects which mimic menopause* including loss of bone density.
*hot flushes, loss of libido, vaginal dryness, mood disturbances
Describe the different types of surgical management?
Laparoscopic laser ablation +/- adehesionolysis
Ovarian cystectomy: drainage of endometrioma, the cyst wall is either stripped away from the ovarian storm or ablated.
May be followed up with GnRH treatment to prevent recurrence.
Note: symptomatic relief is only achieved in 70%
Radical surgery = hysterectomy with bilateral salpingo-oopherectomy (last resort treatment and only for women who have completed there family, will need follow up HRT)
What is the prognosis of endometriosis?
Benign.
Disease often recurs after cessation of medical treatment and may recur after surgical treatment.
Disease will improve after menopause.
What the differentials for endometriosis?
Adenomyosis
PID
Chronic pelvic pain
IBS
What is adenomyosis?
Adenomyosis is presence of endometrial tissue in the myometrium.
How does adenomyosis present?
Similarly to endometriosis:
Dysmenorrhoea
Menorrhagia
Dyspareunia
Aka painful heavy periods and pain with sex.
Smoothly enlarged uterus on examination
