Endometriosis and chronic pelvic pain Flashcards
What is endometriosis?
the presence and growth of tissue similar to endometrium outside the uterus
• 1-2% of women are diagnosed as having endometriosis
particularly between the 30-45yrs (most common in nulliparous)
• Endometriotic lesions may occur in 1-20% of all women, asymptomatically
What is the pathophysiology of endometriosis?
• Endometriosis is oestrogen dependent (regresses after the menopause and during pregnancy)
• It can occur throughout the pelvis, particularly in the uterosacral ligaments and on/behind the ovaries
it can also affect the umbilicus, abdominal wound scars, the vagina, bladder, rectum and even the lungs & brain (rare)
• Accumulated altered blood is dark brown, forms a ‘chocolate cyst’ or endometrioma in the ovaries
• Endometriosis causes inflammation, with progressive fibrosis and adhesions- in its most severe form, the
entire pelvis is ‘frozen’ and the pelvic organs rendered immobile by adhesions
What is the aetiology of endometriosis?
result of retrograde menstruation
more distant foci may result from mechanical, lymphatic or blood-bourne spread
• Affected women have an impaired immune system- endometriosis deposits show evidence of both neuro- and angiogenic activity, leading to increased density of adjacent nerve fibres, hence pain
Genetic link
• A new popular theory is that endometriosis is the result of metaplasia of coelomic cells
What are the clinical features of endometriosis?
• It is an important cause of chronic pelvic pain and usually cyclical, but may be asymptomatic
• Presenting complaints include
o Dysmenorrhoea before the onset of menstruation
o Deep dyspareunia
o Subfertility
o Pain on passing stool (dyschezia) during menses
o Menstrual problems
What are the signs of endometriosis in advanced disease?
- Rupture of endometriosis ovarian cysts is uncommon
- Cyclical haematuria, rectal bleeding or bleeding from the umbilicus are uncommon
- In advanced cases the uterus is retroverted and immobile (adhesions)
What is seen on laparoscopy in endometriosis?
laparoscopy- diagnosis is only made with certainty after visualisation ± biopsy- active lesions are red vesicles or punctate marks on the peritoneum. white scars or brown spots (‘powder burn’) represent less active endometriosis.
while extensive adhesions and ovarian endometriomas indicate severe disease
What are the other investigations for endometriosis?
Transvaginal USS- excludes the diagnosis of an ovarian endometrioma. Can show adenomyosis
• MRI ± intravenous pyelogram & barium study- peritoneal endometriosis will not be visualised on USS, but may be on MRI. used if there is clinical evidence of deeply infiltrating endometriosis, ureteric, bladder or bowel involvement
What is the management for endometriosis?
consideration should be given to removing endometriomas in view of the risk of misdiagnosis ovarian cancer
• Pain may be treated with hormonal drugs to suppress ovarian activity and is appropriate without a definitive diagnosis
some women want to avoid hormone therapy and can manage pain with NSAIDs
What is the medical management for endometriosis?
COCP- widely used and highly accepted- often used back-to-back to reduce frequency of painful withdrawal bleeds
Progestogens- used on a cyclical or continuous basis
GnRH analogues- act by inducing a temporary menopausal state via negative feedback, reversible bone demineralisation limits therapy to 6 months, although it can be used for up to 2yrs with add-back HRT
Danazol and gestrinone- synthetic compounds with androgenic effects (severe side effects)
IUS- reduces pain, especially dysmenorrhoea
What is the surgical management for endometriosis?
o Scissors, laser or bipolar diathermy- used laparoscopically at the time of diagnosis to destroy endometriotic lesion
surgery may also improve conception rates, so is preferable to medical treatment for women with endometriosis-related pain and infertility
o Radical surgery- dissection of adhesions, removal of endometriomas and even hysterectomy with bilateral salpino-oophorectomy (BSO)
How does endometriosis affect fertility?
- Endometriosis is found in 25% of laparoscopies foes investigation of subfertility
- If the fallopian tubes are not affected- medical treatment will not increase fertility, but laparscopic excision or ablation of deposits may
- Drainage and stripping of ovarian endometrioma cysts improves fertility- compared to drainage and cyst wall ablation
- With severe disease affecting the fallopian tubes- surgery has limited benefit and IVF is the best option
What is chronic pelvic pain?
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
presents in primary care as often as migraine or low back pain
affects 15% of adult women
What are the investigations for chronic pelvic pain?
a full history will prevent non-gynaecological diagnoses being missed
psychological evaluation is helpful in some patients
transvaginal USS, MRI or laparoscopy as appropriate
What are the causes of pelvic pain?
• Pelvic pain that varies considerably over the menstrual cycle may be due to hormonally drive gynaecological conditions- including endometriosis or adenomyosis
there may adhesions and ovarian tissue can become trapped within them causing cyclical pain- treated by oophorectomy and adhesiolysis
• Symptoms suggestive of irritable bowel syndrome or interstitial cystitis are often present in women with CPP
• Psychological factors- depression and sleep disorders are common, a substantial number give a history of sexual or physical abuse
What is the management for chronic pelvic pain?
• Women with cyclical pain should be offered a therapeutic trial of COCP or GnRH analogues with add-back HRT for a period of 3-6months before having a diagnostic laparscopy if the pain is unresolved
progestogens and IUS should also be considered
• Counselling and psychotherapy
drugs such as amitriptyline and gabapentin may be used to manage the pain
