Endometriosis And Pelvic Pain Flashcards
Endometriosis definition
The presence of endometrial glands and stroma outside the uterus
Epidemiology of endometriosis
Affects 5-10% of the female population
Up to 20% are asymptomatic
40-60% with secondary dysmenorrhea (cyclic pelvic pain)
20-30% in women with sub fertility
Incidence of endometriosis
3-10x greater if 1st degree relative affected
Anomalous anatomy obstructing menstrual flow
Nulliparity
Subfertility
Prolonged interval since pregnancy
Subfertility
Fertile ability, but impairment of that ability causing longer time to get pregnant
Endometriosis Etiology
- Retrograde menstrual flow
- Coelomic metaplasia
- Lymphatic and/or vascular metastasis
- Transformation of embryonic rests
- Altered cellular immunity
- Genetic, hormonal, environmental
Common locations of endometriosis
- Peritoneal
- Ovarian
- Deep (ex. When the tissue is eroding and constricting deeper structures)
Characteristics of endometriosis
Inflammatory
Vascular network (angiogenesis)
Cellular proliferation
Estrogen dependent
Heterogeneity of endometriosis
Superficial implants Ovarian endometrioma (tend to be blood filled, at risk of torsion) Deep endometriosis
Cardinal symptoms of endometriosis and presentation
*Dysmenorrhea - generally achy that precedes menstruation
*Dyspareunia - usually with deep penetration
*Dysuria
Dyschezia
*3 most common
Can also present with lower back or abdominal or pelvic discomfort or pain
Chronic pelvic pain - non cyclic abdominal pain and pelvic pain 6+ months
Atypical presentations
Cyclic pain at other sites
Rectal bleeding, he matures
Cyclic displeased, hemoptysis
What’s the deal with pain in endometriosis?
No correlation between pain scores and explicable causes
Surgical removal can improve pain scores, but it can also recur without any residual tissue left after checking pathology and for other sources
Screening and diagnosis of pelvic pain
History, PE
Imaging (u/s) - CHECK THE KIDNEYS (can obstruct ureter lower in the pelvis)
Ancillary for deeply invasive - Colonoscopy, cystoscope, rectal u/s, MRI
Gold standard - direct visualization with laparoscopy and histology
U/S sign pathognomonic for endometriosis
Kissing ovaries - large ovaries touching each other and filling cul de sac
Management of endometriosis
Medical
- First line
1. Suspected endometriosis - CHC therapy (usually continuous)
2. Progestins - Second line
1. GnRH agonist with addback - Lupron induces temporary menopausal state by suppressing estorgen and progesterone (injection given monthly)
2. IUS
3. Danazole
Any treatment trial should be administered for minimum 3 months with evaluation of efficacy at the end of the trial
Non-Hormonal treatments treating the pain alone - increase patient comfort until primary medical management (hormonal treatment) becomes effective
- NSAIDs/acetaminophen
- Opioids
- Treat associated conditions (ex. Depression, IBS)
Surgical
Asymptomatic patient with incidental finding of endometriosis does not require any medical or surgical intervention
Decision for surgery based on clinical evaluation, imaging and effectiveness of medical management.
Indications for surgery:
- Uncertainty of do (ex. Chronic pelvic pain, ?adhesive ds)
- Patients with pelvic pain
1. Not responding or with contraindications to medical therapy
2. Acute adnexal event *torsion, rupture)
3. Severe invasive disease involving bowel, bladder, ureters or pelvic nerves (having failed medical management)
4. Pts with infertility
- Patients who have a known or suspected ovarian endometrioma
- Pt wishes definitive surgery - hysterectomy +/- BSO
MOA of CHC
Progesterone for suppressing pain to induce atrophy of implants?
Difference between conservative and definitive approach to endometriosis
Conservative - restore normal anatomy and relieve pain
- women of reproductive age who wish to conceive in future or avoid induction of early menopause
- direct ablation,
INCOMPLETE
Benefit of laparoscopic surgery resection in endometriosis
Reduces pelvic pain
Some studies have shown similar reduction in pain compared to GnRHa
Pain is often decreased, problem is recurrence of pain in 30-60% of women with 6-12 months
Limitations of conservative surgery
- Missed lesions - false negative laparoscopy
- Associated risks of surgery - previous multiple surgeries with suspected or known severe adhesions
- BMI
Post-surgical medical therapy in endometriosis
SURGERY IS NOT THE CURE
- Conservative
1. CBCs over progestin if not seeking pregnancy
2. Postop hormonal suppression associated with lower recurrence rate of ovarian endometriomas and better management of symptoms - Definitive surgery
1. Consider continuous combined CHC or progestin therapy
Adenomyosis diagnosis
Pathology
Therefore hysterectomy must be completed
