Endometriosis Flashcards
What is endometriosis?
A chronic oestrogen dependant condition characterised by the growth of endometrial tissue in sites other than the uterine cavity
What sites are most commonly involved in endometriosis?
- Pelvic cavity
- Uterosacral ligaments
- Pouch of Douglas
- Rectosigmoid colon
- Bladder or distal ureter
What other sites are more rarely involved in endometriosis?
- Umbilicus
- Scar sites
- Pleura
- Pericardium
- CNS
What is the prevalence of endometriosis?
Estimated to effect 10-15% of women of reproductive age
Why is it difficult to determine the prevalence of endometriosis?
- Because of diversity of symptoms and their severity
- Endometriosis may be asymptomatic
Who does endometriosis have a higher prevalence in?
Infertile women
What is the prevalence of endometriosis in infertile women?
25-40%
In what age group is endometriosis found in?
Almost exclusively in women of childbearing age
At what age does the diagnosis of endometriosis most commonly occur?
30’s
What are the risk factors for endometriosis?
- Early menarche
- Late menopause
- Delayed childbearing
- Short menstrual cycles
- Long duration of menstrual flow
- Obstruction to vaginal outflow
- Genetic factors
What can cause obstruction to vaginal outflow?
- Hydrocolpos
- Female genital mutilation
- Defects in uterus or Fallopian tubes
What indicates that there are genetic factors involved in endometriosis?
The risk of endometriosis in first-degree relatives with severe endometriosis is 6x that of relatives of unaffected women
What factors are protective against endometriosis?
- Multiparity
- Use of oral contraceptives
What are the main symptoms of endometriosis?
- Dysmenorrhoea
- Dyspareunia
- Cyclic or chronic pelvic pain
- Subfertility
What other symptoms may be present in endometriosis?
- Bloating
- Lethargy
- Constipation
- Low back pain
What are the less common symptoms of endometriosis?
- Cyclical rectal bleeding
- Menorrhagia
- Diarrhoea
- Haematuria
How does the clinical presentation of endometriosis vary?
Some women experience severe symptoms, whereas some women have no symptoms at all
What happens to the severity of symptoms of endometriosis with age?
Tends to increase
Can endometriosis be asymptomatic?
Yes
How might endometriosis be detected if the patient is asymptomatic?
Diagnosed incidentally or during investigations for infertility
What proportion of women with infertility have endometriosis?
1/3
What % of women with endometriosis are infertile?
40%
How does endometriosis cause infertility?
Exact mechanism is unknown, but possible mechanisms include;
- Anatomical distortions and adhesions
- Release of factors from endometriotic cysts which are detrimental to gametes or embryos
What is often found on examination in endometriosis?
Examination is normal
What findings, if any, might there be on examination in endometriosis?
- Posterior fornix or adnexal tenderness
- Palpable nodules in the posterior fornix or adnexal masses
- Bluish haemorrhagic nodules visible in posterior fornix
What are the differential diagnoses of endometriosis?
- Pelvic inflammatory disease
- Ectopic pregnancy
- Torsion of ovarian cyst
- Appendicitis
- Primary dysmenorrhoea
- Irritable bowel syndrome
- Uterine fibroids
- Urinary tract infection
What is the gold standard for investigation for most forms of endometriosis?
Laparoscopy
What is the problem with laparoscopy in the diagnosis of endometriosis?
Invasive with small risk of major complications
Give a complication of laparoscopy
Bowel perforation
What other investigations may be performed in endometriosis?
- MRI scan
- Transvaginal ultrasound
When might MRI scan be useful in endometriosis?
In non-invasive diagnosis, especially for sub-peritoneal deposits
Why do investigations need to be done in an acute setting of endometriosis?
To exclude important differentials
What investigations are performed to rule out differentials in acute endometriosis?
- Blood tests
- Urinalysis
- Cervical swabs
- ß-hCG
Is there a cure for endometriosis?
No
What are the types of intervention for endometriosis?
- Treatment of pain
- Treatment of endometriosis-associated infertility
What will abate the process of endometriosis in many women?
Menopause - natural or surgical
What is the goal of management of endometriosis in women in reproductive years?
- Provide pain relief
- Restrict progression of the process
- Restore or preserve fertility where needed
In what % of patients does medical treatment reduce the symptoms of endometriosis?
80-90%
Which of the treatment options for endometriosis have been shown to reduce the recurrence of symptoms once treatment has stopped?
None of them
What might the management of endometriosis involve?
- Suppression of ovarian function for at least 6 months
- Surgical options
- Pain management
- Fertility management
What is the basis for most medical treatment of endometriosis?
Suppression of ovarian function
What are the options for the suppression of ovarian function?
- COCP
- Medroxyprogesterone acetate
- GnRH agonist
Does hormonal treatment improve fertility in endometriosis?
No
What are the surgical options for the management of endometriosis?
- Laparoscopy
- Stripping of endometriomatas
- Hysterectomy with salpingo-oophrectomy
What management can be performed for endometriosis at the time of diagnostic laparoscopy?
Laparoscopic excision or ablation
What are the main conservative surgical techniques for endometriosis performed by laparoscopy?
- Thermal or laser ablation
- Excision
- Ovarian cystectomy
- Denervation procedures
What are endometriomatas?
Large cysts or endometriosis
What is hysterectomy with salpingo-oophrectomy reserved for in endometriosis/
Last resort
What is the general principle for the management of pain in endometriosis?
Create a pseudo-pregnancy or pseudo-menopause
How is a pseudo-pregnancy/menopause achieved in endometriosis?
Suppression of ovarian function
What analgesics are commonly used for reducing pain in endometriosis?
NSAIDs, e.g. naproxen, or paracetamol with or without codeine
Is medical or surgical management more effective for addressing infertility associated with endometriosis?
Surgery
What form of surgical management is effective for addressing infertility associated with endometriosis?
Attempts to remove endometrial tissue and preserve the ovaries without damaging normal tissue
What is an appropriate treatment for infertility related to endometriosis?
IVF
When in particular is IVF an appropriate treatment for infertility associated with endometriosis?
If there are co-existing causes of infertility and/or other treatments have failed
What are the complications of endometriosis?
- Fertility problems
- Adhesions
- Ovarian cysts
- Increased risk of ovarian cancer
How can moderate-to-severe endometriosis lead to infertility?
Can cause tubal damage leading to infertility
What are lesser degrees of endometriosis associated with, with regard to fertility?
Sub-fertility and increased risk of ectopic pregnancy, even in absence of obvious tubal damage
What can adhesions lead to in endometriosis?
Bowel and ureter obstruction
