Endometriosis and Chronic Pelvic Pain Flashcards
Define endometriosis
Presence of endometrial tissue outside of the uterus
What is the prevalence of endometriosis?
1 in 10 women of reproductive age have endometriosis
Endometriosis affect 1.5M women
Second most common condition after fibroids in gynaecology
What causes endometriosis?
- No exact cause of endometriosis
- 5 main theories
- Retrograde menstruation (Sampson’s theory) - this is where the endometrial cells flow backwards from the uterine cavity, through the fallopian tubes, and implant on pelvic organs, where they can seed and grow.
- Metaplasia of coelomic epithelium into endometrial glands (Meyer’s Theory) - this described a process by which cells in the pelvic and abdominal area change into endometrial-type cells of the germinal epithelium.
- Vascular and lymphatic dissemination - it has also been suggested that endometriotic tissue may also be able to travel to distant sites (such as the lungs, eyes, and brain) through the lymphatic system or in the bloodstream
- Immune - many women with endometriosis appear to have reduced immunity to other conditions.
- Genetic - genetic predisposition to endometriosis has been well documented in family and twin-based studies, but no specific gene has been identified.
- Also, Environmental factors — this theory suggests that certain environmental toxins can affect the body, immune system, and reproductive system and cause endometriosis. Animal studies have shown the development of endometriosis in animals following exposure to high levels of dioxin
What are the RFs of endometriosis?
- Early menarche.
- Late menopause.
- Delayed childbearing.
- Nulliparity.
- Family history.
- Vaginal outflow obstruction.
- White ethnicity.
- Low body mass index (BMI).
- Autoimmune disease (an increased prevalence of autoimmune diseases has been noted in women with surgically confirmed endometriosis)
- Late first sexual encounter.
- Smoking.
Describe the pathophysiology of endometriosis.
- The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis. → Deposits of endometriosis in the bladder or bowel can lead to blood in the urine or stools.
- Localised bleeding and inflammation can lead to adhesions. Inflammation causes damage and development of scar tissue that binds the organs together. Adhesions lead to a chronic, non-cyclical painthat can be sharp, stabbing or pulling and associated with nausea.
- Endometriosis can lead to reduced fertility. Often it is not clear why women with endometriosis struggle to get pregnant. It may be due to adhesions around the ovaries and fallopian tubes, blocking the release of eggs or kinking the fallopian tubes and obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.
Describe the clinical presentation of endometriosis.
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
- Cyclical abdominal or pelvic pain
- Deep dyspareunia (pain on deep sexual intercourse)
- Dysmenorrhoea (painful periods)
- Infertility
- Cyclical bleeding from other sites, such as haematuria
There can also be cyclical symptoms relating to other areas affected by the endometriosis:
- Urinary symptoms
- Bowel symptoms
Examination may reveal:
- Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
What are the investigations for endometriosis?
TVUS/Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
What grading system is used for endometriosis? What are the stages?
The American Society of Reproductive Medicine (ASRM) has a staging system for endometriosis. - not in NICE guideline
- Stage 1: Small superficial lesions
- Stage 2: Mild, but deeper lesions than stage 1
- Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
- Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
What are the management options for endometriosis?
- Initial conservative management
- Hormonal Management
- Surgical management
What is the initial conservative management for endometriosis?
Consider a short trial (for example 3 months) of paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) for first-line management of pain.
What is the hormonal treatment for endometriosis?
• COCP
o It can be taken for 21 days with a 7-day pill-free break but it may be more effective at alleviating symptoms if tricycled (3 packets taken back to back)
o It can also be taken without a break to induce amenorrhoea
o If this achieves symptomatic relief, it can be continued for several years until pregnancy is intended. Do not offer if trying to conceive.
o Ifineffective,considertreatmentforco-existingconditions(e.g.IBS)andchangingthe medical management
• Progestogens - Used to induce amenorrhoea in those with contraindications for the COCP. Do not offer if trying to conceive.
o The depot-medroxyprogesterone acetate and levonorgestrel IUS are particularly effective for providing long-term therapeutic effect (particularly after surgery)
o Can also use the progesterone only pill or the implant (Nexplanon)
• GnRH Agonists (e.g. Leuprorelin)
o Effective at relieving the severity and symptoms of endometriosis
o Usually administered as slow-release depot formulations (lasting 1 month or more)
o It should not be used for > 6 months because of the risk of osteoporosis
o Also available as multiple, daily-administered intranasal sprays
What is the surgical treatment for endometriosis?
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Fertility-Sparing Surgery
o Laparoscopy is used to both diagnose and treat endometriosis – excision or ablation. Preferred management if fertility is a priority.
o Adjunct: 3 months of GnRH agonists prior to surgery
o Hormonal treatment can be considered post-surgery to manage symptoms
o Risk of recurrence following surgery is as high as 30% so long-term medical therapy is often necessary and started straight after surgery
o Specialist surgery may be needed if the endometriosis has caused extensive adhesions or involved other organs
Hysterectomy and Oophorectomy
o Hysterectomy with removal of the ovaries and all visible endometriosis lesions should be considered in women who have completed their family and failed to respond to conservative treatments
o The woman should be informed that hysterectomy will NOT necessarily cure the symptoms or the disease
How should we counsel a patient with endometriosis?
Define chronic pelvic pain.
Intermittent or constant pain in lower abdomen or pelvis for 6m duration, not occurring exclusively with menstruation or intercourse
What are the investigations for chronic pelvic pain?
- Suitable samples to screen for infection, particularly Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of pelvic inflammatory disease (PID).
- All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs).
- TVS is an appropriate investigation to identify and assess adnexal masses.
- TVS and MRI are useful tests to diagnose adenomyosis.
- The role of MRI in diagnosing small deposits of endometriosis is uncertain.
- Diagnostic laparoscopy has been regarded in the past as the ‘gold standard’ in the diagnosis of chronic pelvic pain. It may be better seen as a second-line investigation if other therapeutic interventions fail.
- Ca125
