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Reproductive Medicine > Endometriosis and Adenomyosis > Flashcards

Endometriosis and Adenomyosis Flashcards

1
Q

What is endometriosis?

A

Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature

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2
Q

What is chronic pelvic pain defined as?

A

Constant or intermittent pain in the lower abdomen or pelvis of a woman of at least 6 months duration and not associated with pregnancy

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3
Q

What is thought to be the cause of endometriosis?

A

Not really known, but theories exist:

  • Retrograde menstruation?
  • Metaplasia of mesothelial cells?
  • Impaired immunity - failure to destroy retrograde menstrual cells
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4
Q

What are causes of chronic pelvic pain?

A
  • Endometriosis
  • Adenomyosis
  • Ovarian cysts
  • Scar tissue and adhesions
  • IBS
  • Interstitial cystitis
  • Chronic PID
  • MSK - nerve entrapment
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5
Q

What are common sites for endometriotic deposits to occur?

A
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6
Q

What are common symptoms of endometriosis

A
  • Severe dysmenorrhoea
  • Chronic pelvic pain
  • Deep dyspareunia
  • Ovulation pain
  • Cyclical/perimenstrual symptoms
  • Chronic fatigue
  • Dyschezia
  • Cyclical rectal bleeding
  • Infertility
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7
Q

Why can pain in endometriosis be cyclical responding to the menstrual cycle?

A

Endometrial tissue responding to hormonal changes in mesntrual cycle

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8
Q

Why can pain be constant in endometriosis?

A

Due to adhesions that form due to chronic inflammation

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9
Q

What is dyschezia?

A

Difficulty defecating

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10
Q

What might you find on examination of someone with endometriosis?

A
  • Thickened pelvic ligaments
  • Blue nodules in posterior fornix
  • Fixed, immobile, retroverted uterus
  • Ovarian enlargement/adnexal masses
  • Adnexal tenderness
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11
Q

What is the classic sign seen in endometriosis on examination?

A

Fixed, retroverted uterus

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12
Q

What are thought to be the mechanisms behind infertility in endometriosis?

A
  • Dyspareunia - reduced frequency of sex
  • Inactivation and phagocytosis of sperm by antibodies and macrophages
  • Fibrial damage, reduced tubal motility
  • Anovulation
  • LUF syndrome
  • Luteolysis caused by prostaglandin
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13
Q

What investigations would you consider doing in someone with suspected endometriosis?

A
  • Bloods - FBC (if menorrhagia)
  • Imaging - TVUSS, MRI Pelvis, Rectal USS
  • Other - Diagnostic laparoscopy
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14
Q

What might you see on TVUSS?

A
  • Ovarian endometrioma (homogeneous, low-level echoes)
  • Deep pelvic endometriosis such as uterosacral ligament involvement (hypoechoic linear thickening)
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15
Q

What might you see on diagnostic laparoscopy in someone with endometriosis?

A

Direct visualisation with biopsy-confirmed endometrial glands or stroma outside of uterine cavity - Chocolate cysts, retroverted uterus, endometrioma

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16
Q

How would you manage someone with endometriosis?

A

Determine if main problem is pain or subfertility, or both:

  • Medical - COCP, Oral progestogens, Mirena IUS, GNRH analogues, HRT
  • Surgical - Excision of deposits, Diathermy / laser ablation of deposits, Hysterectomy AND oophorectomy
17
Q

How does COCP help in endometriosis?

A

Suppress the hypothalamic-pituitary-ovarian axis and subsequent oestrogen/progesterone secretion, thereby inducing atrophy of ectopic implants.

18
Q

How do NSAIDS help in endometriosis?

A

There appears to be positive feedback between prostaglandin (PG) synthesis, aromatase activity, and oestrogen production, mediated by abnormally high COX-2 activity in the setting of endometriosis. Superficial, often atypical implants are active PG producer

19
Q

How do GnRH analogues help in endometriosis?

A

Rapidly induce a hypo-oestrogenic state by down-regulating the hypothalamic-pituitary-ovarian axis. An initial rise in gonadotrophins and oestrogen (flare) occurs after administration, but chronic exposure provides the desired response.

20
Q

How do oral progestogens help in endometriosis?

A

Progesterone induces development of the decidua and eventual atrophy of implants. Certain formulations also suppress the hypothalamic-pituitary-ovarian axis, resulting in decreased steroid hormone stimulation of implants.

21
Q

When is surgical management indicated in endometriosis?

A

When medical therapy has failed

22
Q

What are examples of GnRH analogues?

A

Leuprorelin

23
Q

How long should GnRH analogues be used for?

A

< 6 months - Prolonged exposure (>6 months) can lead to an irreversible decrease in BMD

24
Q

If someone had endometriosis and wanted a child but was suffering from infertility, what could you do to help them?

A
  • Controlled ovarian hyperstimulation - clomifene, aromatase inhibitors, FSH, GnRH analogues
  • IVF
  • Therapeutic laparoscopy
25
Q

What are the main complications of endometriosis?

A

Adhesion formation

26
Q

What age group does endometriosis tend to affect?

A

Women of reproductive age

27
Q

What is adenomyosis?

A

This is the presence of endometrial tissue deep within the myometrium

29
Q

What are features of adenomyosis?

A
  • Heavy painful periods
  • Abdominal pressure/bloating
  • Bulky, tender uterus
30
Q

How would you investigate for adenomyosis?

A
  • Imaging - Pelvic USS
  • Other - laparoscopy, Hysteroscopy +/- biopsy
31
Q

What might help in the management of adenomyosis?

A
  • NSAIDs
  • Mirena IUS
  • Uterine artery embolisation
  • Endometrial ablation

Reproductive Medicine (43 decks)

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