Endometriosis

Question 1

Endometriosis - epi

Answer 1

Incidence 10-12% (estimated)

Question 2

Endometriosis - typical presentation

Answer 2

• Two cardinal symptoms = pain and infertility. May also be asymptomatic
  1. Infertility

Pain (often chronic pelvic pain)

2. Cyclic or constant (ectopic endometrial tissue undergoes same cycle, causing repeated inflammation, which may result in the formation of adhesions)
3. Severe dysmenorrhoea (can be due to adenomyosis)
4. Dyspareunia (deep, indicates involvement of uterosacral ligaments
5. Dysuria (involvement of bladder or peritoneum or invasion into bladder), dyschezia and cyclic pararectal bleeding (for rectovaginal nodules with invasion of rectal mucosa)

+ chronic fatigue

Question 3

Endometriosis - examination

Answer 3

Look for
Bimanual pelvic examination for:
1. Adnexal masses (endometriomas) or tenderness
2. Nodules/tenderness in the posterior vaginal fornix or uterosacral
ligaments
3. Fixed retroverted uterus
4. Rectovaginal nodules.

+ 5. Speculum examination of vagina and cervix (rarely, lesions may be visible)

Question 4

Endometriosis - locations

Answer 4

Common sites

1. Pouch of Douglas
2. Uterosacral ligaments
3. Ovarian fossae
4. Bladder/peritoneum

Rare sites
5. Lungs, brain, muscle, eye

Question 5

Endometriosis - ix (2)

Answer 5

1. Transvaginal U/S
   - Endometriomas
   - Endometriosis of urinary bladder/rectum
2. Laparoscopy + biopsy for histological verification
   - Especially important for deep infiltrating lesions
   - Positive is confirmative, negative does not rule it out
   - Endometriomas >3cm should be resected to rule out malignancy (rare)

Question 6

Endometriosis - mx

Answer 6

Mx pain

1. COCP
2. Medroxyprogesterone acetate or other progestagens
3. GnRH analogues (2nd line, should never be used without back-up HRT); danazol (androgenic agent). Limited by significant and potentially irreversible side effects, and may not offer greater benefits than COCP. GnRHa side effects = loss of bone density, hot flushes, vaginal dryness, headaches, depression. Danazol side effects = acne, hirsutism, irreversible voice changes
4. Levonorgestrel-releasing IUD
5. Surgical mx once medical tx has failed. Recommended techniques = coagulation, excision or ablation. Should be done by laparoscopy. Last resort - consider hysterectomy in pts with severe, treatment refractory dysmenorrhoea

Mx subfertility

1. No medical tx can improve fertility in endometriosis patients
2. Surgical tx - coagulation, excision, ablation. Removal of endometriomas, best by cystectomy rather than drainage to reduce recurrence rates. No RCTs exist for efficacy of surgical tx for moderate/severe disease
3. IVF in moderate to severe disease