Endometriosis & Adenomyosis Flashcards
Define endometriosis [1]
What is an endometrioma? [1]
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus
Endometrioma:
- A lump of endometrial tissue outside the uterus
What is an adenomyosis? [1]
Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
Descrribe the aetiology of endometriosis [3]
During menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum.
- This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity.
Other possible causes:
- Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue. OR
- There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer. OR
- a process called metaplasia occurs, from typical cells of that organ into endometrial cells.
NB: exact cause is unknown
Describe the pathophysiology of the symptoms of endometriosis [3]
The main symptom of endometriosis is pelvic pain
- During menstruation as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body.
- This causes irritation and inflammation of the tissues around the sites of endometriosis
- This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis.
Deposits of endometriosis in the bladder or bowel can lead to blood in the urine or stools.
Localised bleeding and inflammation can lead to adhesions:
- Adhesions lead to a chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with nausea.
Why might endometriosis cause subfertility? [3]
The pathophysiology is not fully understood however current theories suggest that endometriotic lesions cause subfertility via:
* The release of cytokines causing acute and chronic inflammation in the fallopian tubes and ovaries, as a result these tissues become scarred and fibrosed, rendering them unable to function
* The formation of adhesions and fibrosis due to lesions between the uterus, ovaries, fallopian tubes and surrounding structures leading to a distortion of the pelvic anatomy
* Ovulatory dysfunction. This is thought to occur due to the formation of endometriomas, chronic inflammation or the surgical removal of deep-rooted endometriomas, which has been linked to the destruction of primordial follicles and scarring of the ovaries
Describe the clinical features of endometriosis [5]
Chronic pelvic pain lasting more than 6 months
Cyclical pelvic symptoms i.e. symptoms that may only present or worsen during menstruation, including:
- Dysmenorrhoea
- Cyclical GI symptoms - painful defecation/ bowel movements
- Cyclical urinary symptoms - pain passing urine and blood in urine
Dyspareunia (deep pain during or after sexual intercourse)
Subfertility in up to 30-50% of women
Describe how a clinical examination may present for a patient with endometriosis [4]
- Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
Describe how you investigate for endometriosis [3]
1st line: Transvaginal ultrasound Identification of:
- Endometriomas (endometrial cysts on the ovary)
- Superficial peritoneal lesions
- Deep endometrial lesions involving the bowel, bladder or ureters
- However: picks up deep lesions, but not superficial.
Abdominal US
- If TVUS refued
Pelvic MRI
* Not used as primary investigation but may be considered to assess the extent of deep endometriosis involving the bowel, bladder or ureters
Laparoscopic surgery
- gold standard way to diagnose abdominal and pelvic endometriosis.
- A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy.
- Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
What blood test might indicate endometriosis? [1]
This is not used to diagnose endometriosis. A raised serum CA125 (> 35 IU/ml or more) may be consistent with having endometriosis however endometriosis can still occur despite a normal serum CA125
Describe how you would differentiate endometriosis with PCOS [3]
Polycystic ovarian syndrome (PCOS):
Similarities:
- pelvic pain & subfertility
Differences:
* irregular & less frequent periods, multiple cysts on USS, presence of simple follicular cysts rather than chocolate cysts/ endometriomas, nil other pelvic findings
Describe the differences and similarites between endometriosis and an ovarian cyst [1]
Ovarian cyst:
- (+): pelvic pain, cyst on USS
- (-): simple follicular cyst not chocolate cyst/ endometrioma, unlikely to cause adhesions or other deposits in pelvic cavity
What is this? [1]
These cysts are filled with menstrual blood
If you find growths or adhesions in the pelvis, what other pathologies do you need to consider? [2]
How would you differentiate? [1]
ovarian cancer and colon cancer are important to exclude after evidence is found of growths and adhesions in the pelvis.
- cancer and endometriosis is the age of presentation, ovarian and colon cancer tend to present most commonly in menopausal/post-menopausal women, and thus endometriosis is significantly less likely in these patients. It is however important to remember that ovarian and colon cancer can still occur in younger
What are the different stages of endometriosis? [4]
Stage I:
- Minimal disease is characterized by isolated implants and no significant adhesions.
Stage II:
- Mild endometriosis consists of superficial implants that are less than 5 cm in aggregate and are scattered on the peritoneum and ovaries. No significant adhesions are present.
Stage III:
- Moderate disease exhibits multiple implants, both superficial and deeply invasive. Peritubal and periovarian adhesions may be evident.
Stage IV:
- Severe disease is characterized by multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions are usually present.
NB: It is worth being aware of this staging system; however, it is not mentioned in the NICE guidelines, and does not necessarily predict the symptoms or the difficulty in managing the condition. NICE recommend documenting a detailed description of the endometriosis rather than using a specific staging system. The ASRM staging system grades from least to most severe:
Describe the different management options for endometriosis [+]
Analgesia:
- A short trial (3 months) of paracetamol or an NSAID alone or in combination should be considered for first-line management of endometriosis-related pain
Hormonal - works by suppressing ovarian function and oestrogen release
- COCP
- POP
- Mirena coil (IUS)
- Medroxyprogesterone acetate injection (e.g. Depo-Provera)
- GnRH agonists
Surgical management options:
* Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions - GOLD STANDARD
- Abdominal hysterectomy with or without bilateral salpingo-oophorectomy is considered to be the most effective and last-line treatment available for treating the symptoms of endometriosis
Describe the complications of endometriosis [4]
- Infertility
- Adhesions, due to the ‘sticky’ nature of endometriotic lesions, leading to inflammation and obstruction of fallopian, GI, and ureteric tracts
- Endometrioma/ chocolate cyst rupture, leading to acute pain and peritoneal signs
- Increased risk of early miscarriage or ectopic pregnancy
- Surgical complications (infection; perforation, bleeding, failure to remove all lesions)
Where is a common place for endmotrial tissue to settle? [1]
Pouch of Douglas
Why might endometriosis have blood in urine / stool as a presenting feature? [1]
Endometrial tissue can grow in bladder / colon
What are the likely causes of cyclical [1] and non-cyclical pain [1] in endometriosis?
Describe the difference in pain between them
Cylical:
- Ectopic endometrial tissue causing shedding of lining of
- Dull like pain
Non-cylical:
- Adesions occuring
- More stabbing in nature
How would you treat fertility in endometriosis? [3]
Surgery:
- clear adhesions surrounding ovaries
- Remove cysts on ovaries
- Normalise position of ovaries / uterus
Describe what is meant by adenomyosis [1]
Which populations is it most common in? [2]
Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus).
It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall. It may occur alone, or alongside endometriosis or fibroids. The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.
What are the features of adenomyosis? [3]
- dysmenorrhoea
- menorrhagia
- enlarged, boggy uterus
- Pain during intercourse (dyspareunia)
Describe how you would dx adenomyosis? [3]
Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.
How do you manage adenomyosis if:
- the patient does not want contraception [2]
- the patient accepts mx with contraception [3]
- other (surgical) options [3]
When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:
* Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
* Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Management when contraception is wanted or acceptable:
* Mirena coil (first line)
* Combined oral contraceptive pill
* Cyclical oral progestogens
Other & Surgical
* GnRH agonists - to induce a menopause-like state
* uterine artery embolisation
* hysterectomy - considered the ‘definitive’ treatment
Why would you do an abdominal exam if ?endometriosis? [1]
ID abdominal wall endometriosis and assess for signs of peritonism
You suspect endometriosis in a patient.
What examinations would you perform? [+]
Abdominal exam:
- ID abdominal wall endometriosis and assess for signs of peritonism
Pelvic exam: speculum and bimanual
- ID areas of tissue present: in cervix or rectovaginal space
- Bimanual exam will ellicit tenderness
What does this image show? [1]
Umbilical endometrial lesion
If deep endometriosis is suspected - what is often the first line Ix? [1]
Pelvic MRI
What is important to note about laparoscopic investigations for endometriosis? [1]
50% don’t reveal anything and can lead to dissapointment for women
Describe what this image shows? [1]
Endometriosis typica: - superficial endometriosis
- blue, black or red lesions often clustered together
- fibrotic tissue which has formed small nodule on peritoneum. can be palpated with surgical instruments
Describe what this image shows? [1]
Superficial endometriosis with fibrosis of nodule at base - caused involution of tissue and caused peritoneal pocket called Alan masters pouch
Describe what this image shows? [1]
Superficial endometriosis
- Tannin deposit caused by endometriosis
NB: looks like a cigarette burn
Deep endometriosis on the bowel
How does the endometriosis lecturer describe how to take COCP? [1]
I tend to recommend ‘flexible extended use’, where the woman takes the pill continuously until she experiences bleeding. She can then stop the pill for 4 days to have a short period and then restart continuously again. This limits the length of period and the number of periods per year and gives greater control.
Describe what is meant by Dienogest? [+]
- Main side effect [1]
- Other advise [1]
Recently licenced POP in the UK after a long delay – only for women with endometriosis
AKA Zalkya®/Visanne®
Less androgenic than other progestogens - so less side effects
Main side effect is vaginal spotting
Manufacturer advises additional contraception
What are the main benefits of Dienogest? [3]
Less androgenic than other progestogens - so less side effects
Particularly useful for:
- Volume reduction of endometriomas
- Reduction of size of deep endometriotic nodule
GnRH agonists can be used for endometriosis.
What might you give alongside this [2]
What management would you also need to do
Give HRT as induces menopausal like state
Encourage excersise and good diet
Give bisphosphinates as GnRH analogues can cause osteoporosis
- Start DEXA scan at time of treatment and repeat after two years
Where should patients with deep endometriosis be treated? [1]
Tertiary endometriosis centres
What advise would you give about endometriosis and subfertility to a patient? [4]
Most women with endometriosis will conceive spontaneously, however, endometriosis is a leading cause of subfertility
Laparoscopic treatment of SPE improves spontaneous fertility rates
Laparoscopic treatment of DPE is more controversial and MDT input is advisable
Ovarian endometriomas result in reduced monthly fecundity rates
