Endometriosis and Dysmenorrhoea Flashcards
What is dysmenorrhoea?
Pelvic pain during menstruation. Usually cramping, suprapubic pain.
What is dyspareunia?
Pain with sexual intercourse (divided into superficial and deep)
What is dyschezia?
Pain with defecation
What is mid cycle pain?
Pain usually felt in an iliac fossa due to ovulation (Mittelschmerz)
Where is dysmenorrhoea usually felt?
- Suprapubic
- thighs
- low back
- iliac fossae
What proportion of women experience severe (8-10/10) dysmenorrhea?
18-21%
What is primary dysmenorrhoea?
Cause unknown; thought to be related to prostaglandin release causing uterine contraction and myometrial angina
What is secondary dysmenorrhoea?
- Endometriosis
- Adenomyosis
- Intracavity mass (IUD, polyp, fibroid)
- Cervical stenosis: haematometra
- Isolated endometrial pocket post endometrial ablation / non communicating uterine horn
What are the superficial causes of dyspareunia?
- Thrush (candidiasis)
- Skin conditions
- Vestibulodynia
What are the skin conditions which may cause superficial dyspareunia?
- Atrophic vaginitis
- Contact dermatitis
- Lichen planus
- Lichen sclerosis
What are the causes of mid - deep dyspareunia?
- Endometriosis
- Adenomyosis
- Adhesions
- Ovarian cysts
- Pelvic floor (spasm, trigger points)
Examination features in dyspareunia work up?
Does anything reproduce pain with sex?
- Cottonbud prodding if localised tenderness at introitus
- VE:
- -prominent tender pelvic floor?
- -palpate outwards 360 degrees
- -assess uterus for bimanual tenderness
What is endometriosis?
Presence of endometrial glands and stoma outside the uterus
What proportion of women have endometriosis?
60-70% women with cyclical pelvic pain symptoms; 10-15% women of reproductive age
What are the theories of endometriosis?
- Implantation spread (retrograde menses)
- Coelomic metaplasia
- Congenital rest cells
- Iatrogenic implantation
- Metastatic spread (lymphatic and haematogenous)
- Direct spread
How may endometriosis present?
- Cyclical pain
- Provoked pain
- Infertility
- Incidental finding
What are the signs of endometriosis?
- Lower abdo tenderness
- Tenderness on PV esp lateral fornices and POD
- Palpable adnexal mass (endometrioma)
- Palpable vaginal nodule or thickening (in POD)
- Uterus “fixed”
How is endometriosis diagnosed?
- Clinical: 60-70% sens
- US (traditional, detect endometriomas)
- Lap: gold standard
Treatment of endometriosis?
- Nothing
- Drugs (analgesics)
- Drugs to suppress hormonal activity (OCP, progestins, GnRH analogues)
- Surgery: ablate / excise or radical (hysterectomy etc)
What is important to tell the patient prior to initiating treatment for endometriosis?
May not fix the pain
What is important in treating infertility associated with endometriosis?
- Check all other causes
- Surgery: remove endometriomas + hydrosalpinges; consider removal of all E
- Early move to IVF
- Plan pregnancies sooner rather than later
What is adenomyosis?
Endometrial glands and stroma in myometrial layer of uterus
What are the classic symptoms of adenomyosis?
- Menorrhagia
- Dysmenorrhoea
What are the classic signs of adenomyosis?
- Bulky uterus
- Uterus tender on bimanual palpation
Treatment options for adenomyosis?
- Nothing
- Drugs: NSAIDS, OCP, progestins, GnRH analogues
- Mirena IUD
- Surgery (hysterectomy / myomectomy, endometrial ablation)
What is the natural history of primary dysmenorrhoea?
Reduces with:
- age
- increasing parity
- OCP use
Treatment options for primary dysmenorrhoea?
- Do nothing
- NSAIDs
- OCP
- Progestins
- GnRH analogues
- Mirena IUD
- Hysterectomy
- Accupuncture
- Nifedipine / GTN / busocpan
