Endometriosis and chronic pain Flashcards
Definition of endometriosis and epidemiology
Presence and growth of tissue similar to endometrium outside uterus
1-2% women, 30-45 y/o, mainly nulliparous women
endometriotic lesions 1-20% asymptomatically
Endometriosis pathology
occur in pelvis (uterosacral ligaments, on or behind ovaries)
occasionally affects umbilicus/abdominal wound scars, vagina, bladder, rectum, lungs
accumulated blood dark brown -> CHOCOLATE CYST or ENDOMETRIOMA in ovaries
-> inflammation -> fibrosis and adhesions
severe form = pelvis is ‘frozen
Sx
O/E
Tenderness/thickening behind uterus or in the adnexa
advanced cases = uterus retroverted and immobile (due to adhesions) and a rectovaginal nodule of endometriosis on digital examination or visible on speculum posterior to ervix if full thickness vaginally
usually normal pelvis feel with mild endometriosis
Ddx
Mx of endometriosis
A 17-year-old obese girl presents with worsening dysmenorrhea. She began menarche aged 9, and her periods were initially fine. In the last 2 months, they have been more painful, and she has had to take days off school due to the pain. She has not tried any medications for the pain and has never been sexually active.
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
Ddx:
- Adenomyosis
- Chronic PID
- Chronic pelvic pain
- other causes of pelvic masses
- IBS
Clinical features
- chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Investigation
- laparoscopy is the gold-standard investigation
- there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
- NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
- AVOID OPIATES/CODEINE as could worsen co-existing IBS
- if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried → more effective tricycled (3 packs back to back)
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
- GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- drug therapy unfortunately does not seem to have a significant impact on fertility rates
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
Endometriosis PACES TIPS
Chronic pelvic pain: definition
Chronic pelvic pain (CPP) is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse. CPP presents in primary care as often as migraine or low back pain and affects about 15% of adult women. It carries a heavy social and economic price.
Chronic pelvic pain Ix
Holistic
long time
Chronic pelvic pain causes/sx
adenomyosis and endometriosis
IBS or interstitial cystitis common presentations
psychological factors = depression and sleep disorders
Chronic pelvic pain mx
IBS = dietary change, antispasmodics
analgesia or even amitriptyline, gabapentin for pain
cyclical pain = COCP, GnRH analogue with add-back HRT 3-6months before having diagnostic laparoscopic, consider progestogen IUS
counselling and psychotherapy, pain mx programmes
Endometriosis at a glance
Endometriosis at a glance
