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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
Q

What is the definition of chronic pelvic pain?

A

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
Q

What is the aetiology of chronic pain?

A

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
Q

What treatment is there evidence for, in the context of chronic pelvic pain?

A

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
Q

What is the embolisation theory of endometriosis development?

A

Endometrial cells may spread via lymph of blood vessels to ectopic sites.

29
Q

What are the most common sites of endometriosis (from most to least common)?

A

Ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments.

30
Q

How do endometriomas cause infertility?

A
  • Inflammatory
  • Distorted anatomy
  • Destruction of ovarian cortex
31
Q

What are risk factors for endometriosis?

A
  • 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
Q

What factors decrease risk of endometriosis?

A
  • Multiple births
    • Extended periods of lactation
    • Late menarche
    • Increased consumption of long-chain omega-3 fatty acids
33
Q

What non-hormonal medication options are available for endometriosis treatment?

A
  • Analgesics: paracetamol, NSAIDs, others.

Neuromodulators:

  • TCA, SNRI
  • Gabapentin, pregabalin
34
Q

What are the indications for laparoscopic surgery for endometriosis?

A
  • Pain persistent despite medical therapy.
  • Severe symptoms limiting function
  • To restore distorted anatomy
  • Infertility

Note: NOT for diagnostic purposes only.

35
Q

Diagnostic laparoscopy + excision fo peritoneal endometriosis (not deep) and excision of uncomplicated endometriomas:

What are the benefits?
What are the risks?

A

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
Q

What is recommended following all endometriosis surgery (except for fertility)?

A

Hormonal treatment e.g. Mirena, COCP for secondary prevention of endometriosis-related pain and endometriomas

37
Q

What negative outcomes/effects does endometriosis have on pregnancy?

A

Increased risk of:

  • Miscarriage
  • Ectopics
  • APH
  • Placenta praevia
  • Abruption
  • Preeclampsia
  • CS
  • MROP
  • NND
38
Q

Outline the parameters measured in the ENZIAN system for endometriosis staging.

A

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
Q

List the findings on the rASRM classification system that would correlate with stage IV (Severe) endometriosis:

A

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
Q

List the findings on the rASRM classification system that would correlate with stage I (mild) endometriosis:

A

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
Q

Describe the appearance of focal adenomyosis (adenomyoma)

A

Resembles a fibroid but without the pseudocapsule.

42
Q

Describe the macroscopic and microscopic appearance of diffuse adenomysos

A

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
Q

What is the incidence of adenomyosis

What age group is most affected?

A

20-35%

Women in their 50s

44
Q

What is the pathophysiology of HMB in adenomyosis?

A
  • Increased endometrial surface area.

- Overexpression of inflammatory mediators

45
Q

What are the risk factors for adenomyosis?

A
  • High parity

- Vigorous curettage of uterus

46
Q

What additional findings do you get with MRI pelvis diagnosis of adenomyosis?

What are the advantages and disadvantages cf. pelvic USS?

A
  • 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
Q

Management of adenomyosis:

What are the surgical options?

What are the medical options?

A

Surgical:

  • Hysterectomy
  • Uterus sparing resection
  • Uterine artery embolisation

Medical:

  • Hormonal
  • NSAIDs
  • Tranexamic acid
48
Q

Compare and contrast the surgical options for management of adenomyosis

A 
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
Q

Compare and contrast the medical options for management of adenomyosis

A

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
Q

What is the difference between primary and secondary dysmenorrhoea?

A

Primary: pain related to periods in absence of demonstrable disease.

Secondary: same but has a disorder that could account for symptoms.

51
Q

Outline causes of secondary dysmenorrhoea

A

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
Q

What is the pathophysiology of primary dysmenorrhoea?

A
  • Excessive endometrial PGF2.
  • Increased PGF2 to PGE2 ratio
  • Dysrhythmic uterine contractions, hypercontractility, increased muscle tone and uterine ischaemia
53
Q

What are risk factors for primary dysmenorrhoea?

What are protective factors for primary dysmenorrhoea?

A

Risk factors:

  • Young age
  • Smoking
  • Stress

Protective factors:

  • Young age at first childbirth
  • Multiparity
  • Use of hormone contraception
54
Q

What history is suggestive of secondary dysmenorrhoea?

A
  • 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
Q

Chronic pelvic pain assessment:

What red flag symptoms need further investigation and referral to a specialist?

A 
○ 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
Q

Chronic pelvic pain assessment:

What is the utility of identifying soft marker on pelvic USS i.e. probe tenderness or poor ovarian mobility?

A

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
Q

What are the principles of surgical management of endometriosis?

A
  • 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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