Endometriosis and Adenomyosis

Question 1

Definition of Endometriosis

Answer 1

Presence of endometrial tissue (glands and stroma) outside the endometrial cavity

Question 2

2 most common sites of endometriosis

Answer 2

Ovary

Peritoneum

Question 3

Other sites of Endometriosis

Answer 3

Posterior Uterus, Broad Lig, Uterosacral Lig, Fallopian Tubes, Posterior and Anterior Cul de Sac, Colon, Appendix

Question 4

4 Theories of Endometriosis

Answer 4

1. Lymphovascular spread
2. Metaplasia
3. Retrograde Menstruation
4. Altered Immune System

Question 5

Lymphovascular Spread of Endometriosis

Who proposed?
What does it say?

Answer 5

Halban

Endometrial tissue carried through the lymphovascular system to the distant sites

Question 6

Metaplasia Theory of Endometriosis

Who proposed?
What does it say?

Answer 6

Meyer

The peritoneal epithelium is multipotent and that it can differentiate into an endometrial tissue

Question 7

Retrograde flow of Endometriosis

Who proposed?
What does it say?

Answer 7

Sampson

Due to an obstruction in the genital tract, menstruation flows in a retrograde manner causing implantation of endometrial tissue in the peritoneum

Question 8

Altered Immune System of Endometriosis

What does it say?

Answer 8

The body has an altered immune system hence it cannot clear out the ectopic endometrial tissue/implants

Question 9

How is Endometriosis diagnosed?

Answer 9

By surgical confirmation

Question 10

2 most common complaints?

Answer 10

Infertility (30-40%)

Chronic Pelvic pain (20%)

Question 11

True or False:

Severity of symptoms is correlated with the amount of ectopic implants.

Answer 11

False

Question 12

What are the risk factors?

Answer 12

Nulliparity
Early Menarche
Prolonged Menses
Mullerian Anomalies

Question 13

% chance of developing if with a first degree relative (mother or sister)

% chance if no family history

Answer 13

7%

1%

Question 14

What is the hallmark symptom of Endometriosis

Answer 14

Cyclic Pelvic pain beginning 1-2 weeks prior to menses, peaking 1-2 days before onset of menses and subsides at the onset.

Question 15

Other symptoms of Endometriosis

Answer 15

Dysmenorrhea
Dyspareunia
Abnormal bleeding
Bladder and Bowel Symptoms
Subfertility

Question 16

Characteristic of Dysmenorrhea sec to Endometriosis

Answer 16

Starts at the 3rd decade
Worsens as the patient ages
Immediately after menarche, no episodes of dysmenorrhea but would later develop as the patient ages

Question 17

The reason of dyspareunia in endometriosis

Answer 17

Due to deep penetration which can aggravate the implants located on the cul de sac and uterosacral ligaments

Question 18

The reason for infertility in endometriosis

Answer 18

Chronic inflammation due to the implants causes fibrosis and adhesions along the genital tract which hinders tubal mobility and oocyte release.

Adhesions can also cause obstruction.

Question 19

When do you perform IE in endometriosis?

Answer 19

During early menses.
It is during this time when the implants are engorged or inflammed. Nodularities on the uterosacral ligmament can be palpated. Tenderness on RVE. Uterus can be fixed retrovertedly. If with ovarian involvement, there can be an adnexal mass present.

Question 20

How is Endometriosis diagnosed?

Answer 20

Through direct visualization with laparotomy or laparoscopy.

Question 21

Gross appearance of Endometriosis?

Answer 21

Rust colored to dark brown powder burns or raised blue-colored mulberry or raspberry lesions.

At the ovary, chocolate cyst.

Question 22

Ddx?

Answer 22

For cc of pelvic pain:
PID, IBD, Adenomyosis, Interstitial Cystitis, Pelvic Adhesions

For cc of adnexal mass:
functional ovarian cyst, ectopic pregnancy, ovarian neoplasms (ONG)

Question 23

When to do expectant management?
When to do medical management?
When to d surgical management?

Answer 23

> if there is minimal or nonexistent symptoms
if the patient no longer desires to be pregnant
if the patient desires to be pregnant

Question 24

Medical Management of Endometriosis

What are the drugs that can be given to induce a state of “pseudopregnancy”? How does it work? What are the advantages?

Side effects?

Answer 24

1. NSAIDS
2. Estrogen-Progestin Contraceptives
3. Progestin Only

Suppresses ovulation and menstruation
Decidualizes the implants hence decreasing pelvic pain

Best for patients who are not wanting to be pregnant.

Irritability, depression, breakthrough bleeding, bloating

Question 25

Medical Management of Endometriosis

What are the drugs that can be given to induce a state of “pseudomenopause”? How does it work? What are the advantages?

Side effects?

Answer 25

1. Danazol (androgen derivative)
2. GnRH Agonists (Leuprolide Acetate and Nafarelin)

Suppression of FSH and LH. No ovulation and no production of estrogen.

No stimulation of implants. Atrophy of the existing ones. Prevention of new implants.

Danazol - androgen related anabolic side effects (acne, oily skin, weight gain, edema, hirsutism)

GnRH - estrogen deficiency (hot flashes, osteopenia/porosis, headache, vaginal atrophy, dryness)

Question 26

Medical Management of Endometriosis

Other drugs and their MOA

Answer 26

Aromatase Inhibitors (Anastrazole)
Prevents the conversion of androgens to estrogen; off label use; currently still not recommended for endometriosis

Question 27

What is the “Add-Back Therapy”?

Answer 27

Designed to combat the side effects of GnRH which is estrogen deficiency.

Along with GnRH administration, patients can also be given low doses/small amounts of progestin +/- estrogen. Treatment ca be continued upto 1 year.

Question 28

2 main types of surgical management for endometriosis

Answer 28

Conservative and Definitive.

Conservative - Laparoscopy + Fulguration of the endometrial implants; cystectomy of endometriomas

Definitve - THBSO, Adhesiolysis, removal of visible implants