Endometriosis

Question 1

Define ectopic

Answer 1

Abnormal

Question 2

Define endometriosis

Answer 2

Ectopic endometrial tissue (endometrium + stroma) growing OUTSIDE endometrial cavity + uterine musculature.

Question 3

Epidemiological picture of Endometriosis

Answer 3

Tall, white successful business woman and partier from the Northern Suburbs.

• tall
• white
• slim
• smoking
• nullparity
• 25-29 years.

+family history
+autoimmune disease.

Question 4

What are the 3 different types of endometriosis seen, and what are their features?

Answer 4

1. Superficial - seen in surrounding fibres.
   Superficial Peritoneal Endometriosis (SPE)
   - ‘powder burn’ white plaques -
   Seen: serosa, peritoneum, ovaries.
2. Medium - seen local organs (tubes + bowel)
   Endometrioma (OMA)
   - chocolate filled, adherent cysts + surrounding fibrosis.
   Seen: Ovaries, tubes + Bowel.

3. Deep - seen bigger local organs
Deep Infiltrating Endometriosis (DIE)
- infiltrate >5mm. 
Seen: surrounding organs/tissues:  
uterosacral ligaments, vagina, bowel, bladder, ureters.

Question 5

What are the clinical features of Endometriosis (5D’s +3)

Answer 5

5D’s:

• Dysmenorrhea
• Dysuria
• Dyschezia (pain defecating)
• Dysparaunia
• Diarrhea

+ Cyclicity
+ Infertility.
+ Depression (30-85% of women with endometriosis).

Question 6

What investigations are involved in endometriosis

Answer 6

Bedside
- Speculum
- Bimanual (fixed retroverted uterus, rectovaginal nodules, stiffening of US ligaments.
- ensure palpation of POD and both Uterosacral
ligaments (common places).
- Palpation: pelvic mass

Imaging

• Laparoscopic = Gold Standard. : visualisation + bx.
• TVS (endometrioma only) - ground glass.
• MRI: DIE, assess bladder/bowel/ureter involvement.

Question 7

What is the management of endometriosis

Answer 7

If fertility not desired - medical management of sx: 
1st line:  OCP
2nd:  GnRH analgoue
3rd: Progesterone. 
4th: Androgens. 

If fertility desired:
- laparoscopic removal (to prevent infertility).
Deep: Excise + Bx
Superficial: Burn
Chocolate cysts: Suck out.  

NB - medical + sx tx gets best results.

• surgical excision
• OCP (sugar pill every 2-3 months).

Question 8

What are the 2 primary pathophysiological factors involved in endometriosis

Answer 8

Retrograde flow + dysfunctional immune system (increased fibrotic formation)

Question 9

How does endometriosis lead to subfertlity

Answer 9

• altered anatomy (tube/ovarian blockage)

- PG overproduction - interrupts uterine functions and prevents implantation.

Question 10

What is the prognosis of endometriosis?

Answer 10

Recurrence - 10-30%.

Adhesion formation: medium risk.

Fertility success: multifactorial (age, anovulation, tubal function, male factors).

Question 11

Where are the common sites of endometriosis deposition

Answer 11

• POD
• Uterosacral ligaments
• Ovaries
• Round Ligament
• Uterovaginal septum.