Endometriosis

Question 1

Definition of endometriosis

Answer 1

Presence of endometriotic tissue outside of uterus. It is hormonally driven, principally by oestrogen. Some women are relatively symptomatic with extensive disease, some have superficial endometriotic deposits with debilitating symptoms
Chronic condition found on pelvic organs outside of uterus

Question 2

Who is typically affected by it?

Answer 2

Women of reproductive age, particularly 30-45 (some 1-2% of women)
More common in nulliparous
Those with endometriosis FHx
More common in infertile women

Question 3

What is adenomyosis?

Answer 3

Presence of endometrial tissue in myometrium

Question 4

Where does endometriosis classically deposit?

Answer 4

Uterosacral ligaments and on/behind the ovaries

May occasionally affect umbilicus or abdo wound scars, vagina, bladder, rectum and even lungs

Question 5

What happens to the accumulated blood?

Answer 5

Dark brown, can form a chocolate cyst/endometrioma in ovaries (note tip of iceberg effect - on laparoscopy, a small endometriosis may infiltrate deeply)

Question 6

What happens in the most severe form of endometriosis?

Answer 6

Causes inflammation with progressive fibrosis and adhesions; in severe form, pelvic organs rendered immobile by adhesions

Question 7

Causes?

Answer 7

Unknown but three theories
- Retrograde menstruation (adherence, invasion and growth of tissue)
- Metaplasia of mesothelial cells (explains how tissue can appear in obscure locations e.g. nasal cavity)
- Impaired immunity (cells from retrograde menstruation fail to be destroyed by immune response; also autoimmunity)
Also Mullerian abnormalities (differentiation of coelomic epithelium into endometrial glands)

Question 8

What proportion of the general population have endometriosis?

Answer 8

10-12% general female population estimated to have
20-50% undergoing fertility treatment/chronic pain
40-60% dysmenorrhoea

Question 9

Presentations?

Answer 9

Pain
-Cyclical (due to endometrial tissue responding to menstrual cycle)
-Constant due to formation of adhesions from chronic inflammation
-Severe dysmenorrhoea leading to time off from work/school
-Deep dyspareunia from involvement of uterosacral ligaments
-Dysuria
-Dyschezia (pain defaecating) and/or cyclical rectal bleeding (rectovaginal nodules with invasion of rectal mucosa)
Subfertility
No symptoms (incidental factors)

Question 10

Complications?

Answer 10

Rupture of endometriosis ovarian cysts

Question 11

Examination findings?

Answer 11

Normal if minimal disease
Speculum - lesions of vagina/cervix (rare and sign of deep infiltrating endometriosis)
Bimanual - fixed retroverted uterus (classical sign), adnexal masses or tenderness, tender nodules palpable over uterosacral ligaments

Question 12

Ix?

Answer 12

TVS useful for diagnosis of ovarian endometriotic cysts (but poor identifier of parameters of other disease)
MRI used if bowel involvement
CA125 may be raised
Laparoscopy with biopsy gold standard diagnosis for histological diagnosis (esp for deep infiltrating lesions)

Question 13

What is looked for on diagnosis?

Answer 13

Active lesions are red vesicles or punctate marks on peritoneum
White scars and brown spots (powder burn) represent less active endometriosis
Extensive adhesions and ovarian endometriomas (endometrial cysts) indicate severe disease

Question 14

What other differential diagnoses are possible?

Answer 14

Adenomyosis
Chronic pelvic inflammatory disease
Chronic pelvic pain
Other causes of pelvic masses
IBS

Question 15

What is the medical management?

Answer 15

COCP cyclically or continuous; prostagens PO/IM/SC
Mirena IUS (laparoscopy) - suppress oestrogen-related activity for 6m to relieve symptoms
GnRH analogues e.g. goserelin short term <6m with add back HRT e.g. tibolone. Goserelin can also be used in subfertility to get IVF
Symptom recurrence common
NSAIDs - transexamic acid and Mefenamic acid may also be used (analgesia, RCT benefit inconclusive however)

Question 16

What is the surgical management?

Answer 16

Once medical treatment failed
Laparoscopy using ablation, excision or coagulative techniques to destroy endometriosis
Nodules should be excised and endometriomas removed rather than drained (to prevent recurrence)

Question 17

What happens to pregnancy rates after treatment of mild to moderate disease?

Answer 17

Spontaneous pregnancy rates increases with removal of lesions

Question 18

Should hysteroscopy be considered?

Answer 18

Only as last resort

Question 19

What is the surgical classification of endometriosis?

Answer 19

Stage 1 (minimal)
-Findings restricted to only superficial lesions and possible few filmy adhesions
Stage 2 (mild)
-In addition, some deep lesions are present in the cul-de-sac
Stage 3 (moderate)
-As above, plus presence of small endometriomas on ovary and more adhesions
Stage 4 (severe)
-As above, plus larger endometriomas, extensive adhesions

Note that staging correlates very poorly with patient’s symptoms

Question 20

What are the 5 D’s of endometriosis symptoms?

Answer 20

Dyspareunia
Dysmenorrhoea (postmenopausal, characteristic)
Dysuria
Dyschezia (painful defaecation)
Disorders of menstruation (Menorrhagia, IMB, amenorrhoea)

Question 21

Why is it often difficult to diagnose endometriosis in community?

Answer 21

Lots of overlap with similar conditions e.g. IBS

Question 22

What may cause continued pain in patients treated for endometriosis?

Answer 22

Recurrence/worsening of endometriosis
Endometrioma
Chronic pelvic pain

Question 23

How is endometriosis-related infertility managed?

Answer 23

Suppression of ovarian function in mild/moderate endometriosis to improve fertility not effective
Ablation of endometriotic lesions plus adhesionlysis in minimal/mild endometriosis is effective
Laparoscopic cystectomy for ovarian endometrioma of uncertain benefit
Postop hormonal treatment has no beneficial effect on pregnancy rates
Exclude over-riding conditions (severe sperm dysfunction, blocked tubes etc)
If tubes patent, consider ovulation and intrauterine insemination
If diagnosed at laparoscopy - diathermy/laser improves fertility
If not pregnant after 6m - IVF