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B2 Gynaecology > Endometriosis and adenomyosis > Flashcards

Endometriosis and adenomyosis Flashcards

1
Q

What is the definition of endometriosis?

A

Inflammatory disease process characterised by lesions of endometrial-like tissue outside the uterus that is associated with pelvic pain and/or infertility

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2
Q

What is the prevalence of endometriosis in

  • the general population
  • patients attending pain clinic
  • patients attending fertility clinic
A
  • the general population = 10%
  • patients attending pain clinic = 65%
  • patients attending fertility clinic = 50-70%
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3
Q

What are the three “types” of endometriosis?

A
  1. Superficial endometriosis or peritoneal disease <5mm
  2. Ovarian endometriosis / endometriomas (superficial)
  3. Deep endometriosis - Foci of endometrial tissue >5mm in depth, affecting retrocervix, parametric, Rectovaginal septum, digestive tract, ureter, extra-abdominal
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4
Q

What is Sampson’s Theory?

A

Retrograde menstruation

Flow of endometrial content in pelvis allowing implantation of endometrial lesions

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5
Q

What is the theory of coelomic metaplasia?

A

Transformation of peritoneal tissue / cells into endometrial tissue through hormonal and/or immunological factors

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6
Q

What is the hormone theory of endometriosis?

A

Estrogen-driven proliferation of endometrial lesions.

Resistance to progesterone-mediated control of endometrial proliferation

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7
Q

What is the theory of immune dysfunction in endometriosis?

A

Failure of immune mechanism to destroy ectopic tissue and abnormal differentiation of endometriotic tissue

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8
Q

What is the sensitivity and specificity of laparoscopic histological diagnosis of endometriosis?

A 
Sensitivity = 94%
Specificity = 97%

In the absence of histology, the false-positive rate with laparoscopic visualisation alone may approach 50% especially in the mild-moderate endometriosis

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9
Q

How is the inflammatory state of endometriosis thought to impact fertility?

A
  • Toxic effect on gametes, embryos

- Impaired tubal cilia motility

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10
Q

Describe the changes in the eutopic endometrial receptivity

A
  • Increased formation of antibodies to endometrial antigens
  • Resistance to progesterone
  • Decreased expression of integrity and genes regulating implantation
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11
Q

What ovarian cancers is endometriosis associated with?

A

Clear cell
Low-grade serous
Endometrioid

2:100 c.f. 1:100 in the general population

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12
Q

What medical therapy is recommended following excision of endometrioma?

A

COCP
Prevents recurrence

(Unless immediately trying to conceive)

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13
Q

How do progestins help in the management of endometriosis?

A

Inhibit growth of lesions by inducing decidualisation followed by atrophy of uterine-type tissues.
Best hormonal tx for halting disease progression.

No effect on endometrioma recurrence.

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14
Q

What are the adverse effects of progestins?

A

Weight gain
Fluid retention
Depression
Breakthrough bleeding

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15
Q

How does the COCP help to manage endometriosis?

A

Relieves dysmenorrhea through ovarian suppression and continuous progestin administration

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16
Q

How do GnRH agonists help manage endometriosis?

A

Produces hypogonadotrophic hypogonadal state through down regulation of hypothalamus.

Use for 6 months, then stop due to effect on BMD

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17
Q

What are the disadvantages of GnRH agonist use in endometriosis?

A

Cost
Implant
BMD loss
Hypo-oestrogenic side effects

Can minimise side-effects with add back HRT which does not affected efficacy of GnRH agonist

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18
Q

What effect does endometriosis have on pregnancy?

A

Increased risk

  • miscarriage
  • ectopic
  • APH
  • abruption
  • placenta praevia
  • PET
  • PTB
  • MROP
  • NND
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19
Q

What is the definition of Adenomyosis?

A

Deep endometrial tissue surrounded by smooth muscle hyperplasia (usually) within the myometrium
- Focal or DIffuse.

Associated with heavy menstrual bleeding, pain and/or infertility

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20
Q

What is the aetiology of Adenomyosis?

A

Endometrial invasion with alteration in the junctional zone

Misplaced pluripotent Mullerian remnants

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21
Q

What USS features are consistent with adenomyosis?

What is the sensitivity and specificity of USS diagnosis of adenomyosis?

A
  • Bulky, globular uterus
  • Heterogeneous myometrium
  • Venetian blind effect: linear striations radiating from endometrium.
  • Asymmetrical wall thickness (posterior wall thicker).
  • Myometrial cysts
  • Loss of clear endomyometrial border
  • Sensitivity 50-90%
  • Specificity 50-99%
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22
Q

What is the effect of adenomyosis on pregnancy?

A

Increased risk

  • PPROM
  • PTL
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23
Q

What was the finding of the Cochrane Review Overview regarding Endometriosis
- options effective at alleviating pain?
2014

A
  • GnRH analogues
  • LNG-IUD
  • Danazol
  • Progestagens
  • Anti-progestagens
  • Laparoscopic surgical interventions
24
Q

What was the finding of the Cochrane Review Overview regarding Endometriosis
- for women undergoing ART?
2014

A
  • 3 months GnRH agonist improved pregnancy rates
  • excisional surgery improved spontaneous pregnancy rates in the 9-12 months after surgery compared to ablative surgery
  • laparoscopic surgery improved live birth and pregnancy rates compared to diagnostic laparoscopy alone
  • no evidence that medical treatment improved clinical pregnancy rates
25
What is the definition of chronic pelvic pain?
Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy
26
What is the aetiology of chronic pain?
Major changes in both afferent and efferent nerve pathways in the central and peripheral nervous system. Local factors such as TNF-alpha and chemokines may change peripheral nerve function and/or stimulate normally quiescent fibres, resulting in altered sensation over a wider area than originally affected. - Persistent barrage of pain --> CNS changes --> magnifies signal. - Visceral hyperalgesia: pain perception and visceral function modified by previous experience and current circumstances. - Neuropathic pain Frequently more than one factor contributing to chronic pelvic pain
27
What treatment is there evidence for, in the context of chronic pelvic pain?
If endo - hormonal treatment and melatonin If IBS - anti-spasmodiics Amitriptyline, gabapentin NOT enough evidence foR - Botox injection - presacral ensure to my - NO evidence for LUNA
28
What is the embolisation theory of endometriosis development?
Endometrial cells may spread via lymph of blood vessels to ectopic sites.
29
What are the most common sites of endometriosis (from most to least common)?
Ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments.
30
How do endometriomas cause infertility?
- Inflammatory - Distorted anatomy - Destruction of ovarian cortex
31
What are risk factors for endometriosis?
* Nulliparity * Early menarche or later menopause - increased exposure to menstrual debris. * Shorter menstrual cycles (<=27 days) - increased exposure to menstrual debris. * Heavy menstrual bleeding * Obstruction of menstrual flow e.g. Mullerian anomalies * Exposure to DES in utero * Low BMI
32
What factors decrease risk of endometriosis?
* Multiple births * Extended periods of lactation * Late menarche * Increased consumption of long-chain omega-3 fatty acids
33
What non-hormonal medication options are available for endometriosis treatment?
- Analgesics: paracetamol, NSAIDs, others. Neuromodulators: - TCA, SNRI - Gabapentin, pregabalin
34
What are the indications for laparoscopic surgery for endometriosis?
- Pain persistent despite medical therapy. - Severe symptoms limiting function - To restore distorted anatomy - Infertility Note: NOT for diagnostic purposes only.
35
Diagnostic laparoscopy + excision fo peritoneal endometriosis (not deep) and excision of uncomplicated endometriomas: What are the benefits? What are the risks?
Benefits: - Definitive diagnosis - 70% symptomatic relief of mild-mod disease - 90% still have relief after 1 year. Risks: - Recurrence and further surgery - Scarring and adhesions - Surgical and anaesthetic risk - Expensive - Quality of surgery limited by surgeon's abilities
36
What is recommended following all endometriosis surgery (except for fertility)?
Hormonal treatment e.g. Mirena, COCP for secondary prevention of endometriosis-related pain and endometriomas
37
What negative outcomes/effects does endometriosis have on pregnancy?
Increased risk of: - Miscarriage - Ectopics - APH - Placenta praevia - Abruption - Preeclampsia - CS - MROP - NND
38
Outline the parameters measured in the ENZIAN system for endometriosis staging.
Three compartments: - A = posterior cul de sac - B = uterosacrals, cardinals, pelvic side wall, external ureter - C = rectum Three levels of severity of lesion (listed for each A, B, C compartment): - 1 = <1 cm - 2 = 1-3 cm - 3 = >3 cm F= other areas affected by endometriosis including deep endo: - Adenomyosis - Bladder - Ureter intrinsic - Bowel except rectum - Lung, diaphragm, inguinal region etc
39
List the findings on the rASRM classification system that would correlate with stage IV (Severe) endometriosis:
Score >40: - Complete obliteration of the posterior cul-de-sac - Deep lesion of ovaries - >3 cm deep lesion of peritoneum - Adhesion: >2/3 enclosure of ovary - Adhesion: >2/3 enclosure of tube
40
List the findings on the rASRM classification system that would correlate with stage I (mild) endometriosis:
Score 1-5: - Peritoneum: superficial <1 cm - Ovary: superficial <1 cm - Filmy adhesion: <1/3 enclosure of ovary - Filmy adhesion: <1/3 enclosure of tube
41
Describe the appearance of focal adenomyosis (adenomyoma)
Resembles a fibroid but without the pseudocapsule.
42
Describe the macroscopic and microscopic appearance of diffuse adenomysos
Macroscopic: - Thickened myometrial wall - Islands of endometrial bleeding: small haemorrhagic or chocolate coloured areas. Microscopic: - Non-neoplastic endometrial gland and stroma in myometrium. - Surroundingmyometrium is hyperplastic and hypertrophied - Junctional zone (inner myometrium) invasion 2.5 - 8 mm
43
What is the incidence of adenomyosis What age group is most affected?
20-35% Women in their 50s
44
What is the pathophysiology of HMB in adenomyosis?
- Increased endometrial surface area. | - Overexpression of inflammatory mediators
45
What are the risk factors for adenomyosis?
- High parity | - Vigorous curettage of uterus
46
What additional findings do you get with MRI pelvis diagnosis of adenomyosis? What are the advantages and disadvantages cf. pelvic USS?
- Junctional zone (inner myometrium) >12 mm thick. Advantages: - More accurate especially if also fibroids present. - Sensitivity 85% - Specificity 85% - Less invasive (no TV probe) - Quantitate the subendometrial junctional zone thickness Disadvantages: - Expensive - Time consuming - Not readily available - Claustrophobia
47
Management of adenomyosis: What are the surgical options? What are the medical options?
Surgical: - Hysterectomy - Uterus sparing resection - Uterine artery embolisation Medical: - Hormonal - NSAIDs - Tranexamic acid
48
Compare and contrast the surgical options for management of adenomyosis
``` Hysterectomy Advantages: definitive surgery. Disadvantages: - Unable to bear children - Surgical and anaesthetic risks ``` ``` Uterus sparing resection Advantages: - Fertility sparing Disadvantages: - Risk of uterine rupture 4% - Risk of placenta acreta - CS recommended ``` Uterine artery embolisation Advantages: - Less invasive than hysterectomy - For patients who are not good surgical candidates Disadvantages: - High risk of loss of fertility / premature ovarian insufficiency 3% - Failure of treatment 1.5%
49
Compare and contrast the medical options for management of adenomyosis
Hormonal e.g. Mirena, COCP, progestogen, GnRH agonist Advantages: - Fertility sparing - Reduces pain and bleeding Disadvantages: - Contraceptive effect/can't get pregnant while on it - Recurrence within 6 months of stopping - Side-effects of hormones - GnRH agonist: reduced BMD, menopausal sx NSAIDS and TXA: Advantages: - Avoids risks of surgery - May reduce bleeding
50
What is the difference between primary and secondary dysmenorrhoea?
Primary: pain related to periods in absence of demonstrable disease. Secondary: same but has a disorder that could account for symptoms.
51
Outline causes of secondary dysmenorrhoea
Gynae: - Endometriosis / adenomyosis - Fibroids - Ovarian cysts - Adhesions - Chronic PID - Obstructive endometrial polyps - Congenital obstructive Müllerian defects - Cervical stenosis - IUD - Pelvic congestion syndrome - Hematometra Non-gynae: - Inflammatory bowel disease - IBS - Psychogenic
52
What is the pathophysiology of primary dysmenorrhoea?
- Excessive endometrial PGF2. - Increased PGF2 to PGE2 ratio - Dysrhythmic uterine contractions, hypercontractility, increased muscle tone and uterine ischaemia
53
What are risk factors for primary dysmenorrhoea? What are protective factors for primary dysmenorrhoea?
Risk factors: - Young age - Smoking - Stress Protective factors: - Young age at first childbirth - Multiparity - Use of hormone contraception
54
What history is suggestive of secondary dysmenorrhoea?
- Pain onset after age 25 - HMB - Absence of PG excess sx (nausea, vomiting, diarrhoea) - Non-midline pain - Presence of dyspareunia, dyschezia - Progressive severity of sx
55
Chronic pelvic pain assessment: What red flag symptoms need further investigation and referral to a specialist?
``` ○ PR bleeding ○ New bowel symptoms over 50 years of age ○ New pain after menopause ○ Pelvic mass ○ Suicidal ideation ○ Excessive weight loss ○ Irregular vaginal bleeding over 40 years old PCB ```
56
Chronic pelvic pain assessment: What is the utility of identifying soft marker on pelvic USS i.e. probe tenderness or poor ovarian mobility?
The presence of soft markers improve pre-laparoscopy probability of identifying relevant pathology from 58 to 73%. Absence of soft markers reduces probability to 20%
57
What are the principles of surgical management of endometriosis?
* Laparoscopy preferred over open. * Aim to excise / biopsy all suspicious looking lesions. * Excision more effective than ablation. * Aim to restore normal pelvic anatomy where possible. * Endometriomas: incision, drainage and cystectomy to prevent recurrence. * Post-op hormonal treatment to achieve relief from dysmenorrhoea and prevent secondary recurrence.

B2 Gynaecology (12 decks)

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