Endometriosis Flashcards
List four risk factors for endometriosis.
Positive family history Anomalous reproductive tract Nulliparity Subfertility Long inter-pregnancy intervals
List two theoretical etiologies for endometriosis.
Stromal cell defect - abnormal differentiation of endometriotic tissue & failure of immune mechanisms to destroy ectopic tissue
Retrograde menstruation
Coelomic metaplasia (parietal peritoneum is pluripotent)
Circulation & implantation of ectopic menstrual tissue via venous or lymphatic system (or both)
What are your first-line options for medical management of endometriosis?
CHCs (ideally continuous)
Progestins - po, im, subcut
What are your second-line options for medical management of endometriosis?
GnRH agonist w/ addback (may be used long-term, but monitor bone mineral density)
LNG-IUS
True or false: When treating endometriosis with a GnRH agonist, CHCs can be used simultaneously for add-back.
False - you should use much lower doses (similar to doses used for HRT)
Explain why CHCs are ineffective for treatment of endometriosis in some women.
With cyclic use, retrograde menstruation may still occur
Ectopic endometrial implants may have abnormal isoforms of estrogen or progesterone receptors which fail to recognize & respond to the hormones in CHCs
Your patient with endometriosis decides to have an IUS inserted. What would you counsel her regarding the risks of the IUS (specific to endometriosis)?
Possible increased risk of endometriomas as ovulation is not inhibited (ectopic endometrium on the surface of the ovary may undergo invagination into an inclusion cyst, resulting in an endometrioma)
What are the side effects of using danazol to treat endometriosis?
Danazol is a weak androgen - side effects include weight gain, acne, hirsutism, breast atrophy, virilization (rarely), dyslipidemia, possible increased risk of ovarian cancer
How long can you use GnRH agonist with add-back for treatment of endometriosis?
No hard and fast rule, but if well tolerated and loss of BMD not excessive, has been reported used for 5-10 years
Describe your approach to surgical management of ovarian endometriomas. Should they be excised, drained, or cauterized? What size of endometrioma warrants surgery? What, if any, medical treatment should be considered following surgery?
Excision - better pain relief, reduced recurrence compared with drainage or cautery (also allows histologic diagnosis)
Endometrioma > 3 cm warrants excision in women with pelvic pain
Consider CHC following surgery in women not seeking pregnancy (decreases recurrence rate)
What is the definitive surgical management of endometriosis?
Hysterectomy, BSO, excision of all visible endometriotic implants
What is the likely effect on fertility of surgical treatment of the following:
- Minimal/mild endometriosis
- Deep infiltrating endometriosis
- Endometriomas > 3 cm
Minimal/mild endo - improved pregnancy rate regardless of treatment modality (excision vs ablation)
Deep infiltrating endo - controversial
Endometriomas - possible improved fertility
Under what circumstances might you offer hormonal treatment of endometriosis to a woman seeking pregnancy?
Hormonal suppression (GnRH agonist plus add-back x3-6 months) of severe endometriosis prior to IVF increases clinical pregnancy rates, live birth rates, quality of life (less discomfort during IVF) No improved pregnancy rate with hormonal treatment of minimal/mild endometriosis
Adolescents with endometriosis tend to differ from adults with endometriosis. List one historical feature and one exam finding that are more common amongst adolescents.
History - adolescents tend to have acyclic pelvic pain
Physical exam - adolescents tend not to have exam findings as the disease is in an earlier stage
Which medical therapies for endometriosis are contraindicated in adolescents?
None, as long as appropriate counselling has been done
Avoid empiric GnRH agonist treatment, even with add-back, under 18 due to effects on bone mineral density
