Endometriosis Flashcards
What is the definition of endometriosis?
Endometrial tissue outside the endometrial cavity; can get it anywhere excluding the brain, pelvis is most common
What is the pathophysiology?
Retrograde menstruation (Sampson’s theory) - endometrial tissue passes back along fallopian tubes - may settle in the pouch of Douglas (area commonly undergoing some kind of trauma during sex - hence dyspareunia in some people) or other areas of pelvic cavity ; lots of women have this so genetics also play a role as to why these bits of endometrial tissue become cancer-like
Also blood spread or lymphatics spread (Halban’s theory); metaplasia of tissue (Meyers’s theory) - in places further from the pelvis (nose, lungs, any scar tissue e.g. umbilicus)
Most gynae conditions are intimately related to oestrogen (only in the reproductive years) so whilst bleeding isn’t a direct symptom of endometriosis, other oestrogen related conditions e.g. fibroids which are related to bleeding, are strongly associated with endometriosis
How do you investigate endometriosis?
Often a clinical diagnosis - cyclical pain is very significant
USS of part causing pain
CA125 - screening test for cancer (ovarian), though also raised in any condition that irritates the peritoneum (?) - blood test may be done if cyst found in ovaries
How does endometriosis present?
Asymptomatic = most common (often diagnosed incidentally if having other pelvic surgery)
Pain - chronic and recurrent/cyclical - NOT acute (most common cause is appendicitis)
Possible cyclical bleeding - but usually internal so don’t notice or such a small amount also don’t notice also reabsorbed (inflammation can cause adhesions)- may or may not be visible e.g. may bleed monthly into abdominal cavity
Dyspareunia - because of possible locations of endometrial tissue
Women who don’t ovulate regularly or who may be struggling with conceiving or nulliparous patients = more likely as here they have unopposed oestrogen synthesis (progesterone produced by corpus luteum during the second part of the menstrual cycle after ovulation)
Other associated oestrogen related conditions e.g. fibroids (which bleed) or infertility
How do you treat endometriosis?
As with any conditions where oestrogen is the main driver of pathology - give progesterone
How do you manage endometriosis?
Abolish cyclicity:
Combined oral contraceptive pill - even though contains oestrogen, the progesterone comes to dominate; given back to back then have a week off every 3 months so they have a period then back on (need a break as not having one leads to thinning of endometrial lining which then bleeds spontaneously - break through bleeds - reduced compliance) - very effective and cheap treatment
GnRH agonists - block the (60-90 min) pulsatile release of LH and FSH from pituitary gland via GnRH release from hypothalamus (which go on to stimulate ovaries to produce oestrogen); if given exogenously - this agonist can remain in receptor (as opposed to becoming detached so can be re-pulsed in an hour’s time) and mean the body enters into a state of artificial menopause; can’t be on it for long because we get the side effects of menopause - osteoporosis etc; useful to shrink endometriosis before surgery
Glandular atrophy:
COCP
Can give Depot Provera or Minipill = only progesterone (so for patients that have migraines)
Mirena coil
Can’t give these hormonal treatments in women that want to get pregnant
What are chocolate cysts?
Ovaries with endometrial tissue which fill the ovary with blood which then oxidises - looks like chocolate…
How do you grade endometriosis?
Grade 1 - mild - small patches of endometriosis
Grade 4 - frozen pelvis - lots of adhesions all throughout pelvis - to ovaries, uterus, bowel
Symptoms/pain is not related to grade - with minimal you might be affecting the nerve endings = painful, with severe it might not matter so much as everything is fibrotic
How does endometriosis cause infertility?
Possible immunological reaction
How do you manage endometriosis in women who want children shortly?
Surgical ablation of the endometrial tissue
Quicker pain relief than hormonal control
If only treated in this way - may recur if still in women of child bearing age
Also if don’t want babies immediately, can be put in the coil after operation and will be pain free for 5-6 years
IVF may be used in some patients who cannot get pregnant because of severe endometriosis blocking Fallopian tubes - referral to fertility services if 6m trying unprotected vagina sex to get pregnant
What is adenomyosis?
Pockets of endometrial tissue within the myometrium - can bleed also and cause pain
Manage in the same way as endometriosis
