endometriosis Flashcards
categories of ddx that mirror endometriosis
pelvic pain
dysmenorrhea
infertility
pelvic pain ddx
ectopic pregnancy, PID, intersittial cystitis, adenomyosis, ovarian neoplasms , pelvic adhesions, IBS, colon cancer, diverticular disease
dysmenorrhea ddx
adenomyosis, primary dysmenorrhea, uterine leiomyomas
▸ Infertility- ddx
hormonal imbalance, inadequate sperm etc.
bowel symptoms
IBS, inflammatory bowel disease
endometriosis definition
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
when is the diagnosis usually made
- 25-35 years old most common
- Uncommon on pre/post monarchal girls
- Rare in post menopausal women NOT taking estrogen
who do we see this in
thinner taller white women
higher in higher socio economic classes
asian women
increase ris k factors
nuliparity
early menarche or lae menopause
short menstraul cycles
mullerian anomalies
lower risk of endometriosis in
multiple births
extended interval of lactation
late menarch
theories of endo
Retrograde menstruation/Implantation theory
Hematogenous / lymphatic spread
Coelomic metaplasia
Direct transplantation
Combo?
- Endometrial tissue reflux into the fallopian tubes and implant on neighboring structures
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
Hematogenous / lymphatic spread
- Spread to outside location by dissemination of endometrial cells through lymphatics and blood vessels
iii. Coelomic metaplasia
- Coelomic (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue
how does altered immunity play into endometriosis
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
presenatation of CM of enometriosis
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
start to see adhesions in this stage of endometriosis
3
what else would you see in stage 3
moderate disease exhibits multiple implants, bother superficial and invasive, Peritubal and periovarian adhesions
stage 2
mild enometriosis, superficial implants less than 5 cm in aggreagte, scattered on the peritoneum and ovaries. no significant adhesions
stage 1
i. Stage 1: minimal disease—isolated implants and no significant adhesions
stage 4
severe disease, multiple superficial and deep implants, including large ovarian endometrioma. filmy and sense adhesions are usually present
VII. Endometriomas differ from hemorrhagic cysts
hemorrhagic cyst=fild with bloo
endometrioma-soma and glands
Endometriomas would be seen in what stage of endometriosis
4
when would you see endometriomas (chocolate cysts)
d. Detected on imaging (US, CT, MRI)
how do you dx?
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
what is the most common presentation
Dysmenorrhea and Pelvic Pain
onset is usually around
Onset usually several years after menarche in contrast with primary dysmenorrhea which often begins with menarche
pathophysiology of endometriosis
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
Bladder or bowel symptoms
“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
how often do we see infertility with this
Infertility is the presenting symptom in ~ 1/4 of women with endometriosis
PE with endometriosis
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
Labs and imaging
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
what can ULS help with
ii. BUT can detect some findings that can suggest the diagnosis
1. Endometrioma
2. Rectovaginal or bladder nodule
treatment if the pt doesn’t want BC
NSAIDS 400-600 q4-6 hours
avoid cox-2 inhibitors if trying to get pregnant –> just Tylenol
what kind of OCP
MONOPHASIC PILL
but do want withdraw bleed in 3 months
GnRH agonist with add-back
can be used as treatment and (depo-Lupron)
this is NOT birth control need condoms or copper IUD
what is the add-back we use with a gnRH agonist for pain treamtent
progresterone
add-back helps decrease hypoestrogenic effects (hot flashes, night sweats etc.) and preserves bone density
Aromatase inhibitors
are reserved for women who continue to have refractory symptoms despite GnRH agonist treatment
orilissa
will decrease stimulation of the ovaries
GnRH antagonist
aromatase inhibtior
catalyse in the synthesis of estrogen
blocks production but can change voice and
if the patient had no response to treatment or refractory symptoms
laparoscopy for diagnosis and treatment
benefit should outweigh the risk
council patient about reoccurrence rates
(10% in 3 years)
35% in 5 years
