endometriosis and pelvic pain

Question 1

what are the differentials for acute pelvic pain in gynae ?

Answer 1

• ectopic pregnancy
• ovarian cyst (unilateral dyspareunia and palpation pain)
• primary dysmenorrhoea
• mittelshmerz (ovulation)
• non gynae

Question 2

what are the differentials for chronic gynae pelvic pain?

Answer 2

• pelvic adhesions
• fibroids
• cervical stenosis
• Asherman’s syndrome: adhesions in uterus

Question 3

what is ashermans syndrome highly linked with?

what is sheehans syndrome?

Answer 3

• 88% correlation with Dilation and curettage

- hypopituitarism following postpartum haemorrhage and hypovolaemic shock in childbirth

Question 4

what possible investigations would you want to do?

Answer 4

• transvaginal USS
• MRI
• laparoscopy

Question 5

what kind of analgesia may you use?

Answer 5

• paracetamol and ibuprofen

- amytriptiline and gabapentin play a role

Question 6

where is endometriosis most commonly found?

Answer 6

• uterosacral ligaments
• on or behind ovaries
• can also be found in abdominal cavity

Question 7

What is the pathophysiology behind the pain in endometriosis?

what might the endometriosis look like?

Answer 7

• endometrium responds to cyclical hormonal changes and bleeds
• causes irritation of peritoneum
• local inflammation causes fibrosis and adhesions
• adhesions lead to sub fertility and pain
• dark brown blood, forms “chocolate cysts” or endometrioma in the ovary

Question 8

what is the aetiology?

Answer 8

• retrograde menstruation
• sampsons “implantation”
• meyers theory

Question 9

how might they present in endometriosis?

Answer 9

• cyclical pain
• heavy and painful bleeding (most common cause of secondary dysmenorrhoea)
• continuous non-spasmodic pain worse immediately before and throughout menstruation
• menhorragia and passage of clots
• deep dyspareunia (pouch of douglas)
• bowls: constipation, rectal bleeding, dyschezia, IBS (80%)
• bladder: haematuria and retention (obstruction)
• lung: cyclical haemoptysis
• troubled obs history: EmLSCS

Question 10

what might an acute severe pain indicate in endometriosis?

what gynae symptoms should they not get?

Answer 10

• ruptured chocolate cyst

- IMB or PCB

Question 11

what might you find on examination?

Answer 11

• fixed uterus (adhesions)
• retroverted (with adhesions) and tender
• bilateral adnexal tenderness, pain on moving uterus
• thickened pelvic ligaments: uterosacral ligaments (nodular)
• blue nodules in posterior fornix

Question 12

what investigations would you do?

Answer 12

• transvaginal ultrasound can detect gross endometriomas etc
• MRI: can detect lesions which are >5mm in size
• laparoscopies: GOLD STANDARD, often do treatment as well at same time
• CA125 may be raised

Question 13

how is endometriosis treated pharmacologically?

Answer 13

• medical: suppress ovarian function
• COCP (3 months back to back
• progesterone: stops periods, fluid retention, weight gain, PMS, erratic bleeding
• mirena: lighter bleeding and helps dysmenorrhoea
• danazol: androgenic, suppresses ovaries so less oestrogen
• GnRH analogues +HRT (refer to notes)

Question 14

what is the surgical treatment?

Answer 14

• open and drain chocolate cysts
• laparoscopic: ablation, resection of endometriomas/ scar tissue
• hysterectomy

Question 15

what are the complications of endometriosis?

Answer 15

• scarring and adhesions can cause infertility

- endometriomas on ovary “chocolate cysts”