Endometriosis and chronic pelvic pain

Question 1

What is endometriosis?

Answer 1

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

Question 2

What age is endometriosis most common?

Answer 2

Between 30 and 45, it is more common in nulliparous women

Question 3

Does endometriosis change after the menopause?

Answer 3

It regresses after the menopause and during pregnancy because it is oestrogen dependent.

Question 4

Where can endometriosis occur?

Answer 4

It can occur throughout the pelvis, particularly in the uterosacral ligaments, and on or behind the ovaries. Occasionally it affects the umbilicus or abdominal wound scars, the vagina, bladder, rectum and even the lungs

Question 5

What changes can endometriosis cause?

Answer 5

It causes inflammation, with progressive fibroids and adhesion. In severe cases, the entire pelvis is ‘frozen’, the pelvic organs rendered immobile by adhesions

Question 6

What are the causes of endometriosis?

Answer 6

In the pelvis, it is probably a result of retrograde menstruation. More distant foci may result from mechanical, blood-borne or lymphatic spread.

Question 7

What are the clinical features of endometriosis?

Answer 7

Often asymptomatic. Usually cyclical pain. Dysmenorrhoea before the onset of menstruation, deep dyspareunia, sub fertility, pain on passing stool during menses.

Question 8

What would you find on examination of endometriosis?

Answer 8

On vaginal examination: tenderness and/or thickening behind the uterus or in the adnexa. In advanced cases, the uterus is retroverted and immobile.

Question 9

What is a ‘chocolate cyst’ in endometriosis?

Answer 9

Accumulated altered blood is dark from and can form a ‘chocolate cyst’ or endometrioma in the ovaries. If it ruptures it can cause acute pain

Question 10

What investigations would you perform in endometriosis?

Answer 10

Laparoscopy and transvaginal US

Question 11

What needs to be done to make a certain diagnosis of endometriosis?

Answer 11

After visualisation and biopsy, usually at laparoscopy

Question 12

What does endometriosis look like at laparoscopy?

Answer 12

Active lesions are red vesicles or punctate marks on the peritoneum. White scars or brown spots ‘powder burn’ represent less active lesions and ovarian endometriomas indicate severe disease

Question 13

What are the differential diagnoses of endometriosis?

Answer 13

Adenomyosis
Chronic pelvic inflammatory disease
Chronic pelvic pain
IBS

Question 14

What are the medical treatments for endometriosis?

Answer 14

Analgesia (NSAIDs)
Combined oral contraceptive ill
Progestogen
GnRH analogues
Danazol and gestrinone

Question 15

How do hormonal treatments manage endometriosis?

Answer 15

Treatment mimics pregnancy (contraception), the menopause (GnRH analogues) or androgenic (danazol [big side effects])

Question 16

Can the combined oral contraceptive be used back to back?

Answer 16

Yes, to reduce the frequency of painful withdrawal bleeds

Question 17

What are the side effects of progestogen?

Answer 17

Fluid retention, weight gain, erratic bleeding and premenstrual syndrome-like symptoms

Question 18

What are the side effects of GnRH analogues?

Answer 18

They mimic the menopause; reversible bone demineralisation limits therapy to 6 months

Question 19

What are the surgical treatments for endometriosis?

Answer 19

Scissors, laser or bipolar diathermy or radical surgery (hysterectomy and bilateral salpingo-oophrectomy

Question 20

What can be done to increase fertility with endometriosis?

Answer 20

Surgery, such as scissors,laser or bipolar diathermy

Question 21

What is chronic pelvic pain?

Answer 21

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

Question 22

What are the main clinical features of chronic pelvic pain?

Answer 22

Often presents as migraine or lower back pain

Question 23

What are some possible causes of chronic pelvic pain?

Answer 23

Endometriosis and adenomyosis; adhesions and organs trapped in the adhesions; IBS or interstitial cystitis; depression an sleep disorders; history of previous abuse

Question 24

How do you manage chronic pelvic pain?

Answer 24

Analgesics, the combined oral contraceptive and GnRH analogues should be offered. Counselling and psychotherapy involving relaxation techniques such as sex therapy, diet and exercise.