Endometriosis and Chronic pelvic pain

Question 1

1st

Answer 1

1st

Question 2

What is endometriosis?

Answer 2

The presence and growth of tissue similar to endometrium outside the uterus

Question 3

When is endometriosis especially common x2

Answer 3

Nulliparous women

Between age 30-45

Question 4

What is endometriosis growth related to?

Answer 4

Oestrogen dependent - therefore it regresses after the menopause and during pregnancy

Question 5

Where can endometriosis occur?

Answer 5

It can occur throughout the pelvis esp. uterosacral ligaments, behind the ovaries
Also - umbilicus, abdominal wound scars, vagina, bladder, rectum and even lungs

Question 6

What can form as a result of accumulated blood in endometriosis?

Answer 6

Blood is dark brown and can form a ‘chocolate cyst’ or endometrioma in the ovaries

Question 7

What does endometriosis lead to?

Answer 7

Causes inflammation with progressive fibrosis and adhesions
Most severe - the entire pelvis is ‘frozen’
Pelvic organs rendered immobile by adhesions

Question 8

Pathology of endometriosis?

Answer 8

Probably due to retrograde menstruation - blood flowing backwards rather than outwards in menstruation
More distant foci probably from mechanical, lymphatic or blood-borne spread
Degree of genetic inheritance is probable

Question 9

Presentation of endometriosis

Answer 9

Symptoms often absent but is an important cause of chronic pelvic pain - usually cyclical
Otherwise - dysmenorrhoea before onset of menstruation, deep dyspareunia, subfertility, pain on passing stool during menses

Question 10

What is dyschezia?

Answer 10

Pain on passing stool

Question 11

What causes acute pain in endometriosis?

Answer 11

Rupture of a chocolate cyst (in ovary)

Question 12

What are signs of severe disease in endometriosis? x3

Answer 12

Cyclical haematuria, rectal bleeding or bleeding from umbilicus

Question 13

Examination findings with mild endometriosis?

Answer 13

Pelvis often feels normal

Question 14

Examination findings with moderate endometriosis

Answer 14

Tenderness and/or thickening behind the uterus or in the adnexa

Question 15

Examination findings with severe endometriosis?

Answer 15

Uterus is retroverted and immobile due to adhesions

Rectovaginal nodule of endometriosis may be apparent in digital examination

Question 16

Investigations with endometriosis?

Answer 16

Laparoscopy with visualisation and biopsy - is needed to make diagnosis with certainty

Question 17

What is seen on laparoscopy in endometriosis in active disease?

Answer 17

Active lesions - red vesicles or punctate marks on peritoneum

Question 18

What is seen on laparoscopy in endometriosis with less active disease?

Answer 18

Less active - white scars or brown spots ‘powder burns’

Question 19

What is seen on laparoscopy in endometriosis with severe disease?

Answer 19

Severe disease - extensive adhesions and ovarian endometriomas

Question 20

What investigation is good to exclude ovarian endometriomas?

Answer 20

TV USS

Also good to look for adenomyosis

Question 21

What investigation if clinical signs of severe disease - eg. many pelvic organs involved?

Answer 21

MRI +/- IV pyelogram and barium studies

Question 22

When should you treat endometriosis?

Answer 22

When is it symptomatic disease
Common incidental finding
Also regresses in 50% of women

Question 23

Medical treatment for endometriosis?

Answer 23

Some women prefer to manage with analgesics eg. NSAIDs and avoid hormonal drugs
Hormonal drugs that suppress ovarian function (mimics pregnancy or menopause)

Question 24

Who is medication to treat endometriosis not suitable for?

Answer 24

Women trying to conceive because they are contraceptive

Question 25

Different hormonal options for treating endometriosis

Answer 25

COC (not suitable for older women or smokers) - often used 2/3 packs back-to-back, to reduce frequency of withdrawal bleeds
POP - side effects can be severe
GnRH analogues

Question 26

How do GnRH analogues for endometriosis work?

Answer 26

Induce temporary menopause
Overstimulation of pituitary causes downregulation of GnRH receptors - therefore gonadotrophin and ovarian hormone production are reduced
- Side effects = those of menopause

Question 27

How can GnRH analogue treatment be prolonged in endometriosis?

Answer 27

Normally limited to 6months because of effects on bone

Add add-back HRT and can be extended to 2 years

Question 28

Surgical treatment options for endometriosis?

Answer 28

Scissors, laser or bipolar diathermy - laparoscopically to destroy endometriotic lesions
More radical = dissection of adhesions and removal of chocolate cysts
Hysterectomy = last resort

Question 29

Relationship of endometriosis and fertility?

Answer 29

Found in 25% of laparascopies looking at subfertility
Cysts removal improves fertility
If fallopian tubes aren’t affected then medical treatment won’t increase fertility but laparascopic removal of deposits will

Question 30

What is chronic pelvic pain?

Answer 30

Intermittent or constant pain in the lower abdomen or pelvis for at least 6 months duration - not occurring exclusively with menstruation or intercourse

Question 31

Incidence of chronic pelvic pain?

Answer 31

Affects about 15% of adult women - post-menopause is rare

Question 32

Role of oestrogen in chronic pelvic pain

Answer 32

Seems to be important as is rare after menopause and suppression of ovarian activity cures 2/3rd of cases

Question 33

What do women with CPP often have concurrently?

Answer 33

IBS or interstitial cystitis - may be a primary cause or a component of the main

Question 34

What is common in hx for CPP

Answer 34

Abuse of some sort - psychological factors are important

Question 35

Management of CPP

Answer 35

Try COC or GnRH with add-back HRT if cyclical pain

After 3-6months if no improvement then do diagnostic laparascopy