Endometriosis

Question 1

Pathophysiology?

Answer 1

The growth of ectopic endometrial tissue outside of the uterine cavity

Question 2

How common is this condition?

Answer 2

Around 10% of women of a reproductive age have a degree of endometriosis

Question 3

Symptoms?

Answer 3

• Chronic pelvic pain
• Dysmenorrhoea (pain often starts days before bleeding)
• Deep dyspareunia
• Subfertility
• Non-gynaecological symptoms include urinary symptoms e.g. dysuria, urgency and haematuria. Dyschezia (painful bowel movements) can also occur

Question 4

What would a pelvic examination demonstrate?

Answer 4

• Reduced organ mobility
• Tender nodularity in the posterior vaginal fornix
• Visible vaginal endometriotic lesions may be seen

Question 5

Gold-standard investigation?

Answer 5

Laparoscopy

Question 6

What investigation can be used in primary care? Is it useful?

Answer 6

Ultrasound.

Often has a little role and if the symptoms are significant, the patient should just be referred for laparoscopy.

Question 7

How is the correlation between laparoscopic findings and severity of symptoms?

Answer 7

Poor

Question 8

What determines the management?

Answer 8

Severity of clinical features

Question 9

First-line treatments for symptomatic relief?

Answer 9

NSAIDS and/or paracetamol

Question 10

If analgesia helps, what hormonal treatments should be tried?

Answer 10

Combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate

Question 11

When should a patient be referred to secondary care?

Answer 11

When analgesia/hormonal treatment does not improve symptoms or if fertility is a priority

Question 12

What secondary treatments are available?

Answer 12

• GnRH analogues (said to induce a ‘pseudomenopause’ due to low oestrogen levels
• Surgery (treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility)
• Drug therapy does not seem to have a significant impact on fertility rates