endometriosis

Question 1

categories of ddx that mirror endometriosis

Answer 1

pelvic pain
dysmenorrhea
infertility

Question 2

pelvic pain ddx

Answer 2

ectopic pregnancy, PID, intersittial cystitis, adenomyosis, ovarian neoplasms , pelvic adhesions, IBS, colon cancer, diverticular disease

Question 3

dysmenorrhea ddx

Answer 3

adenomyosis, primary dysmenorrhea, uterine leiomyomas

Question 4

▸ Infertility- ddx

Answer 4

hormonal imbalance, inadequate sperm etc.

Question 5

bowel symptoms

Answer 5

IBS, inflammatory bowel disease

Question 6

endometriosis definition

Answer 6

is defined as the presence of endometrial glands and stroma at extrauterine sites

i. Usually located in the pelvis
ii. But can occur nearly anywhere in the body

Common, benign, chronic, estrogen-dependent disorder

Question 7

when is the diagnosis usually made

Answer 7

1. 25-35 years old most common
2. Uncommon on pre/post monarchal girls
3. Rare in post menopausal women NOT taking estrogen

Question 8

who do we see this in

Answer 8

thinner taller white women
higher in higher socio economic classes
asian women

Question 9

increase ris k factors

Answer 9

nuliparity
early menarche or lae menopause
short menstraul cycles
mullerian anomalies

Question 10

lower risk of endometriosis in

Answer 10

multiple births
extended interval of lactation
late menarch

Question 11

theories of endo

Answer 11

Retrograde menstruation/Implantation theory

Hematogenous / lymphatic spread

Coelomic metaplasia

Direct transplantation

Combo?

Question 12

1. Endometrial tissue reflux into the fallopian tubes and implant on neighboring structures

Answer 12

Retrograde menstruation/Implantation theory

Supported by increase incidence in women with genital tract obstructions that prevent expulsion of menses into the vagina

b. However, there are women who have endometriosis but no genital tract obstruction
c. Does not explain how endometriosis gets into other sites

Question 13

Hematogenous / lymphatic spread

Answer 13

1. Spread to outside location by dissemination of endometrial cells through lymphatics and blood vessels

Question 14

iii. Coelomic metaplasia

Answer 14

1. Coelomic (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue

Question 15

how does altered immunity play into endometriosis

Answer 15

Altered Immunity?
a. Deficient cellular immunity and reduction in natural killer cell activity may lead to inability to recognize the presence of endometrial tissue in abnormal locations

Question 16

presenatation of CM of enometriosis

Answer 16

a. Pelvic pain – common complaint
b. Severe dysmenorrhea – will often have to miss school or work b/c periods are so painful
c. Dyspareunia w/ deep penetration
d. Infertility
e. Asymptomatic – may be found on laparascopic surgery for other reasons
f. Constipation/diarrhea
g. Bowel pain
h. Ovarian mass/tumor
i. Dysuria
j. Combination of symptoms
k. Clinical presentation does NOT always correlate to severity of diagnostic findings

Question 17

start to see adhesions in this stage of endometriosis

Answer 17

3

Question 18

what else would you see in stage 3

Answer 18

moderate disease exhibits multiple implants, bother superficial and invasive, Peritubal and periovarian adhesions

Question 19

stage 2

Answer 19

mild enometriosis, superficial implants less than 5 cm in aggreagte, scattered on the peritoneum and ovaries. no significant adhesions

Question 20

stage 1

Answer 20

i. Stage 1: minimal disease—isolated implants and no significant adhesions

Question 21

stage 4

Answer 21

severe disease, multiple superficial and deep implants, including large ovarian endometrioma. filmy and sense adhesions are usually present

Question 22

VII. Endometriomas differ from hemorrhagic cysts

Answer 22

hemorrhagic cyst=fild with bloo

endometrioma-soma and glands

Question 23

Endometriomas would be seen in what stage of endometriosis

Answer 23

4

Question 24

when would you see endometriomas (chocolate cysts)

Answer 24

d. Detected on imaging (US, CT, MRI)

Question 25

how do you dx?

Answer 25

gold standard is surgery but most of the time CM or family hx

▸	Pelvic pain
▸	Severe dysmenorrhea
▸	Dyspareunia
▸	Infertility
▸	Asymptomatic
▸	Constipation/diarrhea	
▸	Bowel pain
▸	Ovarian mass/tumor
▸	Dysuria
▸	Combination of symptoms

Question 26

what is the most common presentation

Answer 26

Dysmenorrhea and Pelvic Pain

Question 27

onset is usually around

Answer 27

Onset usually several years after menarche in contrast with primary dysmenorrhea which often begins with menarche

Question 28

pathophysiology of endometriosis

Answer 28

i. Expanding of endometrial tissue in confined spaces
ii. Increase in cytokines, inflammatory factors
iii. Neighboring nerve irritations b/c of the swelling depending on where the implants are

Question 29

Bladder or bowel symptoms

Answer 29

“Typically” presents as urinary frequency during menses, urinary urgency, suprapubic pain at micturition or urinary retention

Pain during the menstrual cycle

“Typically” presents as diarrhea, constipation, dyschezia (pain with bowel movements), and bowel cramping

Question 30

how often do we see infertility with this

Answer 30

Infertility is the presenting symptom in ~ 1/4 of women with endometriosis

Question 31

PE with endometriosis

Answer 31

Tenderness when palpating posterior vaginal fornix

Lateral displacement of the cervix –> typically seen in patients with adhesions or loss of normal anatomy

Localized tenderness or palpable tender nodule in the posterior cul-de-sac or uterosacral ligaments
Tender, enlarged adenxal
mass —> endometrioma

Pain with movement of the uterus

Retroverted or retroflexed uterus

Question 32

Labs and imaging

Answer 32

No clinically useful labs for diagnosis

i. Some studies being done on CA 125 but sometimes seen with ovarian cysts

Pelvic ultrasound is suggested but rarely helpful

Diagnostic laparoscopy is performed to confirm a diagnosis of endometriosis

Question 33

what can ULS help with

Answer 33

ii. BUT can detect some findings that can suggest the diagnosis
1. Endometrioma
2. Rectovaginal or bladder nodule

Question 34

treatment if the pt doesn’t want BC

Answer 34

NSAIDS 400-600 q4-6 hours

avoid cox-2 inhibitors if trying to get pregnant –> just Tylenol

Question 35

what kind of OCP

Answer 35

MONOPHASIC PILL

but do want withdraw bleed in 3 months

Question 36

GnRH agonist with add-back

Answer 36

can be used as treatment and (depo-Lupron)

this is NOT birth control need condoms or copper IUD

Question 37

what is the add-back we use with a gnRH agonist for pain treamtent

Answer 37

progresterone

add-back helps decrease hypoestrogenic effects (hot flashes, night sweats etc.) and preserves bone density

Question 38

Aromatase inhibitors

Answer 38

are reserved for women who continue to have refractory symptoms despite GnRH agonist treatment

Question 39

orilissa

Answer 39

will decrease stimulation of the ovaries

GnRH antagonist

Question 40

aromatase inhibtior

Answer 40

catalyse in the synthesis of estrogen

blocks production but can change voice and

Question 41

if the patient had no response to treatment or refractory symptoms

Answer 41

laparoscopy for diagnosis and treatment
benefit should outweigh the risk
council patient about reoccurrence rates

(10% in 3 years)
35% in 5 years