Endometriosis and chronic pelvic pain Flashcards
What is endometriosis?
The presence and growth of tissue similar to endometrium outside the uterus.
What age is endometriosis most common?
Between 30 and 45, it is more common in nulliparous women
Does endometriosis change after the menopause?
It regresses after the menopause and during pregnancy because it is oestrogen dependent.
Where can endometriosis occur?
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
What changes can endometriosis cause?
It causes inflammation, with progressive fibroids and adhesion. In severe cases, the entire pelvis is ‘frozen’, the pelvic organs rendered immobile by adhesions
What are the causes of endometriosis?
In the pelvis, it is probably a result of retrograde menstruation. More distant foci may result from mechanical, blood-borne or lymphatic spread.
What are the clinical features of endometriosis?
Often asymptomatic. Dysmenorrhoea- pain often starts days before bleeding Chronic pelvic pain Deep dyspareunia Subfertility Dyschezia Dysuria Cyclical bowel or bladder symptoms including pain and/or bleeding
What would you find on examination of endometriosis?
On vaginal examination: tenderness and/or thickening behind the uterus or in the adnexa. In advanced cases, the uterus is retroverted and immobile.
What is a ‘chocolate cyst’ in endometriosis?
Benign ovarian cyst containing thick, old blood. AKA endometrioma in the ovaries. If it ruptures it can cause acute pain
What investigations would you perform in endometriosis?
Laparoscopy (gold standard) and transvaginal US
What needs to be done to make a certain diagnosis of endometriosis?
After visualisation and biopsy, usually at laparoscopy
What does endometriosis look like at laparoscopy?
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
What are the differential diagnoses of endometriosis?
Adenomyosis
Chronic pelvic inflammatory disease
Chronic pelvic pain
IBS
What are the medical treatments for endometriosis?
- NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
- If analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
- GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- drug therapy unfortunately does not seem to have a significant impact on fertility rates
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
How do hormonal treatments manage endometriosis?
Treatment mimics pregnancy (contraception), the menopause (GnRH analogues) or androgenic (danazol [big side effects])
