Endometriosis and chronic pelvic pain Flashcards
What is endometriosis?
Presence and growth of tissues similar to endometrium outside the uterus.
Which hormone is endometriosis dependent on?
Oestrogen - it regresses after menopause and during pregnancy.
What does endometriosis cause?
Causes inflammation, with progressive fibrosis and adhesions. In its most severe form, the entire pelvis is frozen - the pelvic organs rendered immobile from adhesions.
What is endometriosis probably a result of?
Retrograde menstruation endometrium which then implants and grows - although retrograde menstruation is common and not all women have endometriosis.
Those distant organs affected are probably due to mechanical, lymph or blood-borne spread.
What are the symptoms of endometriosis?
Dysmenorrhoea before the onset of menstruation
Deep dyspareunia
Subfertility
Pain on passing stool during menses
Cyclical haematuria, blood in stools or from the umbilicus are uncommon and suggest severe disease.
What are the common findings of endometriosis on examination?
Tenderness and/or thickening behind the uterus or in the adnexa on vaginal examination.
In advanced stages the uterus can be retrograde and immobile from adhesions.
What investigation is used to diagnose endometriosis and what is found?
Laparoscopy - visualisation and biopsy.
MRI if distant endometriosis thought to be involved - lung, bowel etc.
Active red lesions or punctated marks on the peritoneum.
White scars or brown spots (less active endometriosis).
Adhesions (severe)
White scarring with surrounding abnormal blood vessels
Chocolate cyst in ovaries
What are the medical managements of endometriosis?
Hormonal - suppress oestrogen
1. the pill (combined or progestogens)
2. GnRH analogues - limited to 6 months use due to
reversible bone demineralisation, but can be
extended for up to 2 years using add back HRT.
3. Androgenic - danazol but not really used now due to
side effects
NSAIDs/paracetamol/opiates.
IUS
What are the surgical treatments of endometriosis?
Laparoscopic laser ablation/diathermy/scissors +/- adhesiolysis –> improves fertility
Hysterectomy and bilateral salpingo-oophorectomy
What are endometriosis’ affected on fertility? How is it addressed?
The more severe the endometriosis, the greater the chance of subfertility.
If fallopian tubes are unaffected, medical treatment will not increase fertility, but laparoscopic excision/ablation might.
Drainage and stripping of ovarian endometrioma cysts improves fertility.
With severe disease affecting the fallopian tubes, surgery has limited benefit and in vitro fertilisation (IVF) is the best option.
What is chronic pelvic pain?
Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months which is not occurring exclusively with menstruation and intercourse.
What are some of the causes of pelvic pain?
Pelvic pain that varies considerably over the menstrual cycle may be due to hormonally driven gynae conditions such as endometriosis or adenomyosis.
Oestrogen activity appears to be important as postmenopausal pain is rare - suppression of oestrogen activity appears to relieve 2/3 pain.
IBS or interstitial cystitis are often present.
Depression
Sleep disorders
A substantial number have experienced/are experiencing sexual abuse.
What is the management of chronic pelvic pain?
Treat underlying condition if there is one - depression, IBS, interstitial cystitis.
Cyclical pain - pill/IUD
Analgesia
Too much investigation is counter productive as it can aid a woman’s beliefs about her pain
Counselling and psychotherapy
Amitriptyline or gabapentin
