Endometriosis and Adenomyosis Flashcards
What is endometriosis?
Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature
What is chronic pelvic pain defined as?
Constant or intermittent pain in the lower abdomen or pelvis of a woman of at least 6 months duration and not associated with pregnancy
What is thought to be the cause of endometriosis?
Not really known, but theories exist:
- Retrograde menstruation?
- Metaplasia of mesothelial cells?
- Impaired immunity - failure to destroy retrograde menstrual cells
What are causes of chronic pelvic pain?
- Endometriosis
- Adenomyosis
- Ovarian cysts
- Scar tissue and adhesions
- IBS
- Interstitial cystitis
- Chronic PID
- MSK - nerve entrapment
What are common sites for endometriotic deposits to occur?
What are common symptoms of endometriosis
- Severe dysmenorrhoea
- Chronic pelvic pain
- Deep dyspareunia
- Ovulation pain
- Cyclical/perimenstrual symptoms
- Chronic fatigue
- Dyschezia
- Cyclical rectal bleeding
- Infertility
Why can pain in endometriosis be cyclical responding to the menstrual cycle?
Endometrial tissue responding to hormonal changes in mesntrual cycle
Why can pain be constant in endometriosis?
Due to adhesions that form due to chronic inflammation
What is dyschezia?
Difficulty defecating
What might you find on examination of someone with endometriosis?
- Thickened pelvic ligaments
- Blue nodules in posterior fornix
- Fixed, immobile, retroverted uterus
- Ovarian enlargement/adnexal masses
- Adnexal tenderness
What is the classic sign seen in endometriosis on examination?
Fixed, retroverted uterus
What are thought to be the mechanisms behind infertility in endometriosis?
- 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
What investigations would you consider doing in someone with suspected endometriosis?
- Bloods - FBC (if menorrhagia)
- Imaging - TVUSS, MRI Pelvis, Rectal USS
- Other - Diagnostic laparoscopy
What might you see on TVUSS?
- Ovarian endometrioma (homogeneous, low-level echoes)
- Deep pelvic endometriosis such as uterosacral ligament involvement (hypoechoic linear thickening)
What might you see on diagnostic laparoscopy in someone with endometriosis?
Direct visualisation with biopsy-confirmed endometrial glands or stroma outside of uterine cavity - Chocolate cysts, retroverted uterus, endometrioma
How would you manage someone with endometriosis?
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
How does COCP help in endometriosis?
Suppress the hypothalamic-pituitary-ovarian axis and subsequent oestrogen/progesterone secretion, thereby inducing atrophy of ectopic implants.
How do NSAIDS help in endometriosis?
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
How do GnRH analogues help in endometriosis?
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.
How do oral progestogens help in endometriosis?
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.
When is surgical management indicated in endometriosis?
When medical therapy has failed
What are examples of GnRH analogues?
Leuprorelin
How long should GnRH analogues be used for?
< 6 months - Prolonged exposure (>6 months) can lead to an irreversible decrease in BMD
If someone had endometriosis and wanted a child but was suffering from infertility, what could you do to help them?
- Controlled ovarian hyperstimulation - clomifene, aromatase inhibitors, FSH, GnRH analogues
- IVF
- Therapeutic laparoscopy
What are the main complications of endometriosis?
Adhesion formation
What age group does endometriosis tend to affect?
Women of reproductive age
What is adenomyosis?
This is the presence of endometrial tissue deep within the myometrium
What are features of adenomyosis?
- Heavy painful periods
- Abdominal pressure/bloating
- Bulky, tender uterus
How would you investigate for adenomyosis?
- Imaging - Pelvic USS
- Other - laparoscopy, Hysteroscopy +/- biopsy
What might help in the management of adenomyosis?
- NSAIDs
- Mirena IUS
- Uterine artery embolisation
- Endometrial ablation
