Endometriosis

Question 1

Why does endometriosis cause pain?

Answer 1

Bleeding –> inflammation + fibrosis –> pain

Question 2

Prevalence of endometriosis

Age

Answer 2

Prevalence of endometriosis: 10% of all women, 30% of subfertile women, 60% of women w/ pelvic pain.
Occurs in young women (avg age 28).
Familial predisposition.

Question 3

4 etiology theories of endometriosis

Answer 3

Retrograde menstruation
Hematogenous
Coelomic metaplasia
Immunological

Question 4

Endometrioma
Cause
US appearance

Answer 4

• Endometrioma = ovarian cyst filled w/ endometriotic tissue.
• Metaplasia of the surface of the ovary may lead to endometriomas
• US shows hypoechoic cyst w/ ground-glass appearance

Question 5

2 main sxs of endometriosis

Other sxs

Answer 5

• Pain and infertility
• Pain w/ period and sex are most common.
• Others: dysuria, dyschezia (constipation), infertility, GI (mainly involves rectum and sigmoid; sxs include bloating, pain, change in bowel habits, or anorexia)

Question 6

Physical exam findings of endometriosis (5)

Answer 6

Cul-de-sac tenderness / obliteration, nodularity of uterosacral ligaments, fixed retroverted uterus, ovarian enlargement, lateral cervical displacement

Question 7

Natural history of endometriosis

Answer 7

1/3 improve, 1/3 stay the same, 1/3 get worse

Question 8

Surgical treatment for endometriosis
2 kinds
Efficacy

Answer 8

• Surgery may be conservative (just endometriosis) or extensive (hysterectomy + bilateral salpingo-oopherectomy).
• Pain is improved in 80% of pxs. Slight increase in fertility
• Pxs w/ oopherectomy may require estrogen replacement therapy, which does not increase risk of recurrence.

Question 9

5 medical therapies for endometriosis

Answer 9

• OCPs – estrogen induces progesterone receptor. Progestin is the main component that then treats the sxs and reduces pain.
• GnRH agonists – inhibit LH / FSH secretion → low estrogen. Side effects are menopausal-like
• Progesterone-containing IUDs
• Aromatase inhibitors (require additional progestin to be effective)
• IVF is a last resort

Question 10

How common are fibroids?

Answer 10

80% of women have them, but most are asymptomatic

Question 11

Etiology of fibroids

Answer 11

Fibroids are both estrogen and progesterone-dependent. Increased receptors in fibroids. Fibroids are larger during high estrogen states (pregnancy, high dose OCPs, obesity)

Question 12

Sxs of fibroids (9)

Answer 12

• Pain (pelvic, back, leg), menstrual irregularities, menorrhagia, anemia, GI, bladder, dyspareunia, vascular sxs, infertility
• May cause bleeding if inside the uterus
• Outside the uterus: may cause pressure and press on bowel, cause sciatica, or back pain.

Question 13

Things that increase risk for fibroids (6)

Answer 13

• Early menarche, OCPs before 16 y/o, high BMI, genes, AA

* High estrogen / progesterone, and number of periods (more w/ age) are risk factors.

Question 14

Things that decrease risk for fibroids (5)

Answer 14

Increased parity, progesterone-only injectable contraceptives, fruit, veggies, dairy

Question 15

Treating fibroids
Gold standard
Uterine conserving methods (7)

Answer 15

• Hysterectomy – gold standard due to lowest risk of recurrence.
• Uterine conserving methods
• Observation
• Hysteroscopic / laparoscopic resection (robot-assisted)
• Medical – see next card
• Myomectomy
• Uterine artery embolism
• Radiofrequency ablation
• MRI-guided US thermal ablation

Question 16

Medical treatments for fibroids (5)

Answer 16

Trenexamic acid, progesterone-IUD, OCPs, aromatase inhibitors, GnRH agonists (best medical tx; but bad side effects so only reserved for presurgical treatment). Overall, meds don’t work as well as surgery.

Question 17

Indications for surgical removal of fibroids (4)

Answer 17

Abnormal uterine bleeding, pelvic pressure, urinary frequency, infertility.
Do NOT treat if asymptomatic.

Question 18

Malignant form of a fibroid

Answer 18

Leiomyosarcoma