Endometriosis Flashcards
What is endometriosis?
A condition characterised by growth of ectopic endometrial tissue outside of the uterine cavity
What percentage of women of reproductive age have a degree of endometriosis?
Around 10%
Is there a wide variety in severity of disease and its impact on pain?
Yes
Some women relatively asymptomatic with extensive disease, whilst others only have superficial endometriotic deposits with debilitating symptoms
How does it present?
Pain:
Cyclical due to endometrial tissue responding to the menstrual cycle
Constant due to formation of adhesions from chronic inflammation
Severe dysmenorrhea - time off work or school
Deep dyspareunia (from involvement of uterosacral ligaments)
Urinary symptoms: dysuria, urgency, haematuria
Dyschezia (painful bowel movements) and /or cyclical rectal bleeding
Subfertility
What may be found on examination?
Normal if limited disease
Abdominal - masses
Pelvic - fixed, retroverted uterus = classic sign, enlargement of uterus, tender nodularity in posterior vaginal fornix, might see visible endometriotic lesions
What investigations can be done?
Laparoscopy = gold standard with biopsy - look for endometrial tissue (can cauterise or excise it)
Pelvic USS useful for diagnosis of ovarian endometriotic cysts but poor at identifying other parameters of disease (could be done before laparoscopy if suspecting deep endometrial disease)
MRI if suspecting deep endometriosis involving bowel, bladder or ureter (before laparoscopy)
What marker may be raised?
CA 125 - but should not be used as screening tool
What does management depend on?
Clinical features
Whether main feature is pain or subfertility
What areas are most often affected by endometrial tissue deposits?
Ovaries
Fallopian tubes
Uterine ligaments
Can also affect: perimetrium, rectovaginal septum, recto-uterine pouch (pouch of Douglas), intestines, bladder
What causes the endometrial cell migration?
A number of theories:
1) retrograde menstruation - some blood containing endometrial tissue flows back into the Fallopian tubes and implant into nearby tissue
2) metaplasia of mesothelial cells
3) immune system dysfunction - endometrial cells from retrograde menstruation fail to be destroyed by immune response
4) benign metastases theory - endometrial cells can travel via lymph and blood (explains distant sites e.g lungs and heart)
5) extrauterine stem cell theory - stem cells differentiate into endometrial cells then travel to other parts of body
What are some risk factors?
FH of endometriosis
Never having been pregnant
Early menarche
Late menopause
What are some differences between normal endometrial cells and endometriosis implants?
Implanted cells contain high levels of enzyme aromatase - produce own oestrogen
Implanted cells release pro inflammatory factors - inflammation and scarring - can cause adhesions
Both promote growth of new blood vessels - nourish the tissue
What are chocolate cysts?
If the implanted endometriotic tissue is on the ovaries it can form an endometriomas, also called chocolate cysts
They contain old dark blood and shed tissue - when get too large they can rupture resulting in pain and inflammation
Why is subfertility linked to endometriosis?
The inflammation likely damages/ scars the reproductive structures , which inhibits the release of the egg or its movement
Damage to the uterus can also make implantation more difficult
How is endometriosis managed?
Symptomatic relief: NSAIDS and / or paracetamol
Hormonal to stop ovulation and reduce endometrial thickening - COCP, progestogens, mirena IUS
If analgesia/ hormonal treatment does not improve symptoms or if fertility is a priority, referral to secondary care for treatment:
GnRH analogues - pesudomenopause (can improve the cyclical menstrual pain) - comes with menopause side effects, so add back HRT often recommended
Surgical - once medical treatment failed
Laparoscopy is mainstay - ablation, excision or coagulative techniques to destroy endometriosis
Hysterectomy and bilateral salping-oophrectomy
