Endometriosis and Dysmenorrhea

Question 1

Define:

Dysmenorrhea

Dyspareunia

Dyschezia

Mittelschmerz

Answer 1

Dysmenorrhoea = pelvic pain during menstruation
Dyspareunia = pain during sexual intercourse
Dyschezia = pain during defecation
Mid-cycle pain (Mittelschmerz) = pain usually felt in an iliac fossa due to ovulation

Question 2

Describe the type of pain that is often felt with dysmenorrhea.

Answer 2

• location
  
  • lower half of the abdomen - usually midline
  • back
  • may radiate down the thigh
• cramping pain
• time
  
  • during menstruation = usually day 1-3 then settles
  • may extend pre/post-mentstrual
• severity
  
  • variable
  • 1 in 5 have severe pain.

Question 3

WHat are some causes of dysmenorrhea?

Answer 3

• primary = PG stimulates contractions - arteriolar compression leading to hypoxia and pain.
• secondary - anything in the cavity of the uterus.
  
  • endometriosis
  • adenmyosis
  • intra-cavity mass = IUD/polyp/fibroid
  • cervical stenosis = hematometra

Question 4

Whats a way to differentiate the different types of dyspareunia?

Question 5

What non-menstrual cyclic pain that you should consider in a women presenting with dysmenorrhea?

Answer 5

• mid-cycle pain = D10-D14
  
  • adhesions around ovary stretched, though to be associated with bleeding
• premenstural pain
• postmenstrual pain
• continous pelvic pain
  
  • does it increase with menses? yes - gynae no - are they on contraception?

Others:

• pain on voiding
• pain with defecation
• pain with full bowel
• rectal pain

Question 6

Endometriosis causation theories?

Answer 6

• retrograde menstruation = implantation spread
• implation spread + RF (predisposition - genetic)
  
  • 90% of women have retrograde menstruation but endometriosis is only 10-15%. Smoking decreases incidence.
• coelomic metaplasia
  
  • application of menstrual blood to peritoneum
• Iatrogenic implantation
  
  • C-section - nodule of scar - contaminate an area
• Metastatic spread (rare but can happen)
  
  • lymphatics
  • haematogenous
• direct (through wall into other organs)

Question 7

Endometriosis presentations?

Answer 7

Hx:

• cyclical pain - symptom severity does not correlate well
  
  • pain on void/defecation with period
  • mid-cycle pain
  • premenstrual pain
• provoked pain
  
  • dyspareunia
  • pain on tampons
  • pain on exam
• infertility
• incidental finding (US, operation)

Examination:

• lower abdominal tenderness
• tender on PV exam
• palpable nodule
• fixed uterus

Question 8

How do you diagnose endometriosis?

Answer 8

• clinical 60-70% sensitivity
• US
  
  • traditional = detects endometriosis
    
    • provides difference between cyst
• MRI - not as good - cost
• Laparoscopy - gold standard (have a look)
• common sites:
  
  • most common dependent areas (in the bowel or pelvis) - retrograde menstruation theory.
    
    • Pouch of Douglas
    • Uterovesical fold
    • lateral pelvis alongside fallopian tube (bowel, tubes, side walls).
• appearance:
  
  • early = vesicles (reflecting - white/bluish)
  • red = neoangiogenesis
  • power-spot burn appearance is classic.
  • chocolate cysts - endometriosis

Question 9

What are some treatments of endometriosis and what are the considerations/issues with this?

Answer 9

Issues:

• what has been tried before? and outcomes
• desire for fertility?
• symptom severity
• it is not fatal
• clarify reasons for treatment
• empower patient - inform, education and allow then to make the choice.

Options:

• do nothing
• drugs = simple analgesics
• drugs = suppress hormonal
  
  • OCP continous (monophasic)
  • progestins (Provera-MDPA) - SE from hormones
  • GnRH analogues - induces menopause
• surgery
  
  • ablate/excise lesions 80%
  • radical - remove uterus and ovaries (theories suggest it comes from uterus retrograde - remove source, remove ovaries to stop ovulation).
• may not fix pain (central sensitisation, unknown aetiology).

Question 10

Treating the endometriosis causes for infertility?

Answer 10

• check for other causes
• drugs - no role
• Surgery:
  
  • remove hydrosalpinges - good for IVF
  • remove cysts >3cm
  • remove lesions - if mild might improve natural fertility
• plan pregnancies sooner rather than later
• early move to IVF

Question 11

What is Adenomyosis? What are the classic findings?

Answer 11

• glands and stroma in the myometrium
• Presentation:
  
  • classic symptoms
    
    • HMB (menorrhagia)
    • dysmenorrhoea
    • change in fertility and altered peristalsis
  • classic signs
    
    • bulky uterus
    • uterus is tender to bimanual palpation
• more common than endometriosis - 5-70%, 30% hysterectomy.

Question 12

How do you Manage Adenomyosis?

Answer 12

• Diagnosis:
  
  • US - sensitivity/specificity 85%
• Treatment:
  
  • DO nothing
  • Drugs:
    
    • NSAIDs (ponstan)
    • CP
    • progestins
    • GnRH analogues
  • Mirena IUD - very handy
  • Surgary:
    
    • hysterectomy/myometrium
    • endometrium ablation

Question 13

Primary Dysmenorrhea, what do you do and why?

Answer 13

• absence of pathology but difficult to determine whether its adenomyosis or not.
• Hx - natural Hx? decreases with
  
  • increasing age
  • parity
  • OCP
• Treatment:
  
  • NSAIDs
  • OCP
  • Progestins
  • GnRH analogues
  • Mirena
  • hysterectomy
  • other drugs:
    
    • nifedipine - relax smooth muscle SE: postural HTN
    • GTN - smooth muscle, SE: flushing, headache, low BP
    • buscopan - relax smooth muscle SE: constipation