Endometriosis and Chronic pelvic pain Flashcards
When does endometriosis tend to regress?
During pregnancy and after menopause (it is oestrogen dependent)
Is endometriosis more common in parous or nulliparous women?
Nulliparous
What is the probable cause of endometriosis?
Probably the result of retrograde menstruation
Where in particular is endometrial tissue found within the pelvis?
In the uterosacral ligaments and on or behind the ovaries. (the pelvic organs and the peritoneum are most commonly affected)
Which age of women commonly have endometriosis?
Women of reproductive age
What is the appearance of endometriosis in surgery?
varies from small black lesions to large endometriotic cysts (endometriomas). Can appear as superficial ‘powder-burn’ or ‘gunshot’ lesions, nodules or small cysts containing old haemorrhage.
What are the clinical features of endometriosis?
Severe dysmenorrhea, deep dyspareunia, chronic pelvic pain, ovulation pain, cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal pain or bleeding. Infertility, chronic fatigue, dyschezia (pain on defecation)
Which 2 other conditions have considerable overlap with endometriosis?
IBS and PID
When is endometriosis most likely detected on examination?
During menstruation
What is found on examination of a patient with endometriosis?
Pelvic tenderness, fixed retroverted uterus, tender uterosacral ligaments
What is a chocolate cyst? (classic of endometriosis)
It is accumulated altered blood which is dark brown, can also be an endometrioma in the ovaries
What may be felt on examination of advanced cases of endometriosis?
A rectovaginal nodule of endometriosis may be apparent- i.e. deep infiltrating nodules are palpated on the uterosacral ligaments or in the pouch of douglas and/or visible lesions are seen in the vagina/on cervix
What is the gold standard investigation for endometriosis?
Visual inspection on laparoscopy
Regarding histology, how is endometriosis diagnosed.
Positive histology confirms but negative does not exclue. Histology can exclude rare instances of malignancy in cases of ovarian endometrioma and in deeply infiltrating disease.
Is TVS useful in endometriosis?
This has limited value in diagnosis but is a useful tool to make and exclude the diagnosis of an ovarian endometrioma.
What is the treatment for endometriosis?
Counselling plus analgesia (NSAIDS) and hormonal suppression of ovarian function for 6 months reduces endometriosis-associated pain (oestrogen and progesterone protect against bone mineral density loss)
You can also give progestogens or the COCP to treat endometriosis.
What is the surgery for endometriosis?
Ablation of endometriotic lesions. A radical treatment would be a hysterectomy.
What are the five classes of steroid hormones?
Progestogens, androgens, estrogens, glucocorticoids and mineralcorticoids.
What is the clinical definition of chronic pelvic pain?
Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months duration. It does not occur exclusively with menstruation or intercourse and not associated with pregnancy.
What can chronic pelvic pain typically present as?
Migraine or lower back pain
What should you not forget to ask about chronic pelvic pain?
Musculoskeletal issues- effect on movement or posture
What examination could be carried our for chronic pelvic pain?
Samples to screen for infection (chlamydia, gonnorhoea) if any suspicion of pelvic inflammatory disease (PID)
What is the gold standard investigation for chronic pelvic pain?
Diagnostic laparoscopy
What imaging techniques are appropriate in the diagnosis of chronic pelvic pain?
Transvaginal scanning to screen for assess of adnexal massess.
Which imagining techniques are useful in the diagnosis of adenomyosis?
TV scan and MRI
How do you treat chronic pelvic pain?
Trial with COCP or a GnRH agonist for 3-6 months before having a diagnostic laparscopy
How does the COCP work?
It induces negative feedback resulting in lower levels of FSH, inhibiting follicular development and preventing an increase in estradiol levels. Progestogen negative feedback and the lack of oestrogen positive feedback on LH secretion prevent a mid-cycle LH surge.
How many day packs are the cyclical combined HRT therapies provided and how is this split up in terms of hormones.
28 day packs- the first 14 days contain oestogen only and the following 14 days contain oestrogen and progesterone.
What is the purposeful effect of HRT on the endometrium?
Ideally in the first 14 days the endometrium would be proliferative and in the next 14 days it would be secretory.
What is decidua?
This is a change in the uterine lining (becomes decidualised) due to a pregnancy. This is regardless of whether the embryonal tissue has implanted in the uterine lining or not and therefore this is how the endometrium would appear in a tubal pregnancy for example. This is a normal hormonal effect and it occurs regardless of the implantation site.
Post menopausal bleeding in a woman with no other risk factors is most likely due to what?
Atrophic endometrium
A tumour of the endometrium is most likely what?
Adenocarcinoma
So, from days 1-14 of the cycle, what stage is the endometrium in?
Proliferative phase
What is the first line investigation for a pituitary adenoma?
ct scan following hyperprolactinaemia
In women who have a first degree relative with a venous thrombo-embolism, what blood test should be used to screen them before giving them the COCP?
thrombophilia screen
What is the common presentation in a woman with asherman’s syndrome?
amenorrhoea, hypomenorrhoea
What is D&C?
Dilatation and curretage- the cervix is dilated with a steel rod increasing in size, the endometrium is then curetted.
When is D&C used?
For abnormal uterine bleeding, treatment of missed and incomplete miscarriages and for abortion.
Which drugs are used for abortion?
Misoprostal and Mifepristone
What are the features of nausea and vomiting in pregnancy?
It seldom persists beyond 14 weeks and is more common in multiparous women.
What is hyperemesis gravidarum?
This is when nausea and vomiting in early pregnancy are so sever to cause severe dehydration, weight loss or electrolyte disturbance.
What may predispose to hyperemesis gravidarum and must be ruled out?
Urinary infection, multiple or molar pregnancy must all be excluded.
How is hyperemesis gravidarum treated?
IV rehydration, and anti-emetics such as metoclopramide, cyclizine and even ondansetron and thiamine (to prevent neuro complications of vitamin depletion such as Wernicke’s encephalopathy).
What is a hydratiform mole?
trophoblastic tissue, which is part of the blastocyst invades the endometrium and proliferates in a more aggressive way than normal.
What are the two types of hydratiform mole?
Complete and partial
What is a complete mole?
This is entirely paternal in origin, usually when one sperm fertilises an empty oocyte and undergoes mitosis- the result is a diploid tissue usually 46XX.
What is a partial mole?
This is usually triploid, derived from two sperms and one oocyte- there is variable evidence of a fetus. 69 XXY/ 92XXXY
If invasion of the mole is only within the uterus, what is it referred to as?
Invasive mole
If the mole is invasive with metastasis, what is it called?
Choriocarcinoma
If there is a persistence of elevation of hCG, what is the condition referred to as?
Gestational trophoblastic neoplasia (GTN)
Who is gestational trophoblastic disease most common in? ( this inclludes hydratiform mole, invasive mole, choriocarcinoma and the very rare placental site trophoblastic tumour)
Women of extremes of gestational age and it is twice as common in Asians.
What are the clinical features of gestational trophoblastic disease?
Large uterus, early pre-eclampsia and hyperthyroidism. Vaginal bleeding is usual and there may be severe vomiting (hyperemesis).
What is seen on ultrasound in GTD?
‘snowstorm’ appearance of the swollen villi with complete moles. (grapes)
How is diagnosis of GTD confirmed?
Histologically.
How is GTD managed?
Suction curettage (ERPC), followed by serial hCGs. A continued rise is suggestive of malignancy.
