Endometriosis breadth - passmed Flashcards
What is endometriosis?
Endometriosis is characterized by the growth of ectopic endometrial tissue outside of the uterine cavity, affecting around 10% of women of reproductive age.
What are the clinical features of endometriosis?
Chronic pelvic pain, secondary dysmenorrhea, pain before bleeding, deep dyspareunia, subfertility, and non-gynecological symptoms like urinary issues and dyschezia. Reduced organ mobility and tender nodularity may also be observed on pelvic examination.
What is the gold-standard investigation for endometriosis?
Laparoscopy is the gold-standard investigation for diagnosing endometriosis.
What is the role of primary care in the investigation of endometriosis?
Primary care has little role in investigating endometriosis; significant symptoms should lead to referral for definitive diagnosis.
What are the first-line treatments for endometriosis according to NICE guidelines?
NSAIDs and/or paracetamol for symptomatic relief.
What hormonal treatments are used for endometriosis when analgesia is ineffective?
Hormonal treatments like the combined oral contraceptive pill or progestogens (e.g., medroxyprogesterone acetate).
When should a patient with endometriosis be referred to secondary care?
If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority.
What is the role of GnRH analogues in managing endometriosis?
GnRH analogues induce a ‘pseudomenopause’ by lowering estrogen levels, but do not significantly impact fertility rates.
What surgical options are available for endometriosis?
Laparoscopic excision or ablation of endometriosis, adhesiolysis, and ovarian cystectomy for endometriomas, especially to improve conception chances.
A 30-year-old nulliparous woman presents with severe dysmenorrhoea, heavy & irregular bleeding, pain on defecation and dyspareunia - what is diagnsosis
endometriosis
A 20-year-old G2P1 woman presents to the emergency department with mild vaginal bleeding and abdominal pain. She had a positive urine pregnancy test 6 weeks ago. Ultrasound shows pelvic free fluid and no identifiable intrauterine pregnancy.
This pregnancy was conceived spontaneously. Her first child was born vaginally. Her medical history includes endometriosis and Hashimoto’s thyroiditis. She has never had an STI. Apart from levothyroxine, she takes no regular medications. She does not smoke but drinks alcohol regularly. Her BMI is 33 kg/m2.
What feature puts her at risk of the likely diagnosis?
Alcohol use
Endometriosis
Her BMI
Levothyroxine use
Multiparity
Endometriosis is a risk factor for ectopic pregnancy
The correct answer is endometriosis. The most likely diagnosis for this patient is an ectopic pregnancy, whereby the blastocyst has been implanted in a location other than the uterine endometrial tissue. Abdominal pain and vaginal bleeding are common features in the presentation of ectopic pregnancy, and the diagnosis is confirmed by the absence of an intrauterine pregnancy on ultrasound. The presence of pelvic free fluid could indicate that her ectopic pregnancy has ruptured, and the patient should be transferred to the operating theatre for surgical management. Endometriosis is a recognised risk factor for ectopic pregnancy. The mechanism for this is not well understood but could be related to the laparoscopic procedure required for diagnosis or the presence of endometrial tissue in abnormal locations.
Alcohol use is incorrect because whilst alcohol use is strongly discouraged in pregnancy due to the potential effects on the developing foetus, it has no known association with ectopic pregnancy. In contrast, smoking is a known risk factor for ectopic pregnancy, especially if the patient smokes around the time of conception. This patient does not smoke and there is no other substance or medication history that would increase her risk. She should be counselled on the risks of alcohol in future pregnancies, but it is unlikely to have caused her current pregnancy complications.
Her BMI is incorrect because while having a high BMI is a risk factor for a number of pregnancy-related complications, it is not associated with ectopic pregnancy. Having a high BMI can increase a patient’s risk of early pregnancy loss, diabetes, pregnancy-induced hypertension, preeclampsia, preterm delivery, post-term pregnancy, multi-foetal pregnancy, congenital anomalies, complicated labour, Caesarean delivery, and other postpartum complications. It does not increase the risk of ectopic pregnancy.
Levothyroxine use is incorrect because this medication has no known association with an increased risk of ectopic pregnancy. It is compatible with pregnancy at all stages as well as breastfeeding; in fact, untreated hypothyroidism is associated with poorer outcomes for the unborn child. Thyroid function should be monitored during pregnancy to ensure adequate treatment. This patient’s ectopic pregnancy is unlikely to be related to her regular medication but is more likely associated with her history of endometriosis.
Multiparity is incorrect. This patient has previously had a completed pregnancy without significant complication, meaning that a blastocyst has been able to implant within the uterus in the past. A previous history of ectopic pregnancy is a significant risk factor for a subsequent ectopic pregnancy, which may be due to continuing underlying risks as well as the treatment required for the first one. Any procedure or inflammatory process that can affect the Fallopian tubes increases the risk of ectopic pregnancy. The fact that this woman has had a child in the past does not increase her risk.
A 30-year-old woman presents with ongoing, cyclical pain around the time of her periods. The pain starts several days before the period itself and can last until several days after. She also experiences pain during sexual intercourse, particularly with deep penetration.
Examination demonstrated tender nodularity in the posterior fornix.
The patient has already tried paracetamol and ibuprofen, but these are no longer effective.
What is the next most appropriate step?
Clomifene
Combined oral contraceptive pill
Elagolix
Laparoscopic excision
Leuprorelin
If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried
This patient has endometriosis, as evidenced by her symptoms and findings on examination. First-line treatment involves the use of simple analgesia. As this is no longer effective, the next step is to use either progestogens or the combined oral contraceptive pill. Hormonal treatments are generally effective at controlling endometriosis-related pain.
Clomifene is used to induce ovulation in a number of conditions. While endometriosis can affect fertility and clomifene may be used for this aspect, by an experienced fertility doctor, it would not be the next step in pain management.
Elagolix is a relatively new gonadotropin-releasing hormone antagonist. It is licensed in the USA for endometriosis-related pain. It is not widely used in the UK currently and so the next most appropriate option remains the combined contraceptive pill.
Laparoscopic excision is further down the line, as surgery carries significant risks. The next step, after simple analgesia, is the use of hormonal options.
Leuprorelin is a gonadotropin-releasing hormone agonist. Whilst effective for the control of endometriosis-related pain, it is prescribed by specialists and would not be the next step after simple analgesia.
A 32-year-old woman presents with a history of painful, regular periods. Since stopping the combined oral contraceptive pill eight-months ago her periods are more painful and heavy. She is upset because she would like to conceive but the pain is limiting intercourse. She would like to know the cause of her symptoms.
On examination, her abdomen is soft and non-tender with no masses, but a bimanual examination pelvic examination is limited due to pain.
What is the gold standard diagnostic test for this woman?
CT
Laparoscopy
MRI
Transvaginal and pelvic ultrasound
CA125
Laparoscopy is the gold-standard investigation for patients with suspected endometriosis
Laparoscopy is the gold-standard investigation for patients with suspected endometriosis. It allows direct visualisation and biopsies of the endometrial deposits.
A CT scan may be used to show endometrial deposits but they are less specific than MRI scans.
Ultrasound can be helpful to show endometriomas but a normal scan does not exclude endometriosis.
CA125 is not used to diagnose endometriosis. A raised serum CA125 may be consistent with endometriosis but a normal result does not exclude it.
Pelvic MRI scans should not be used as the primary investigation for endometriosis. They can be helpful before laparoscopy to assess the extent of deep endometriosis, but laparoscopy remains the gold-standard investigation.
Theme: Pelvic pain
A. Appendicitis
B. Ovarian torsion
C. Subacute bowel obstruction
D. Endometriosis
E. Urinary tract infection
F. Ovarian cyst
G. Chronic interstitial cystitis
H. Uterine fibroids
I. Pelvic inflammatory disease
J. Ectopic pregnancy
For each one of the following scenarios please select the most likely diagnosis:
- A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
Pelvic inflammatory disease - A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen.
- A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse.
- A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
Pelvic inflammatory disease
The correct answer is: Ovarian cyst
Large ovarian cysts may lead to abdominal swelling and pressure effects on the bladder.
- A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen.
Appendicitis - A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse.
Endometriosis
This is a characteristic history of endometriosis.
A 28-year-old woman presents with cyclical pelvic pain that is worse around her periods. The pain starts 2 days before the period and lasts until several days after. She has associated dyspareunia and has had some painful bowel movements. Paracetamol and ibuprofen previously helped, however, they no longer do.
An examination reveals generalised tenderness, a fixed and retroverted uterus and uterosacral ligament nodules. Her BMI is 29 kg/m². She would like to start a family next year but does not mind taking contraceptives if she is able to stop and conceive then.
What is the next best step in her management?
Offer combined oral contraceptive pill
Offer medroxyprogesterone acetate
Offer mefenamic acid
Refer for consideration of GnRH analogue
Refer for laparoscopic excision
If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried
Offer combined oral contraceptive pill is correct. This patient has signs and symptoms consistent with endometriosis, characterised by her chronic cyclical pelvic pain, dyspareunia, secondary dysmenorrhoea, and pain with bowel movements. The examination findings support this diagnosis and are commonly seen in people with endometriosis. The first-line option to try in endometriosis is paracetamol with or without an NSAID (usually mefenamic acid or ibuprofen). If these fail, the second-line option is hormonal therapy (e.g. the combined oral contraceptive pill, medroxyprogesterone acetate etc.). Since this patient would like to start a family within the next year, it would be more appropriate to offer the combined oral contraceptive pill, as it is not associated with a delayed return to fertility. Medroxyprogesterone acetate is also known as Depo Provera and provides contraception for up to 12 weeks, but its effects cannot be reversed once given and it is associated with a potential delayed return to fertility (up to 12 months).
Offer medroxyprogesterone acetate is incorrect. Although the combined oral contraceptive pill or a progestogen should be offered if analgesia does not help endometriosis, this patient would like to start a family within the next year, therefore it would be more appropriate to offer the combined oral contraceptive pill, as it is not associated with a delayed return to fertility. Medroxyprogesterone acetate is also known as Depo Provera and provides contraception for up to 12 weeks, but its effects cannot be reversed once given and it is associated with a potential delayed return to fertility (up to 12 months). As well as this, her BMI is 34 kg/m² and a known side effect of the injectable contraceptive is weight gain.
Offer mefenamic acid is incorrect. Analgesia has already been tried without success in this patient. Mefenamic acid is another type of NSAID and would be unlikely to work if ibuprofen is unsuccessful. If analgesia does not help in endometriosis, the combined oral contraceptive pill or a progestogen should be trialled.
Refer for consideration of GnRH analogue is incorrect. This would be considered if hormonal therapy is ineffective. It would be inappropriate to jump to a referral without trialling the combined oral contraceptive pill first.
Refer for laparoscopic excision is incorrect. This would be considered if hormonal therapy and other measures such as GnRH agonists are ineffective. It would be inappropriate to jump to a referral without trialling the combined oral contraceptive pill first, as surgery carries more risks that may not be necessary (e.g. infection and bleeding).
A 26-year-old woman is referred to the gynaecology clinic with severe dysmenorrhoea and a clinical history suggestive of endometriosis. She has tried paracetamol and ibuprofen with little benefit. She is not planning to start a family for the next couple of years. What is the recommended first-line management, providing that there are no contraindications?
Laparoscopic adhesiolysis
Copper intrauterine device
Progesterone injection Depo-Provera
Combined oral contraceptive pill (COCP)
Gonadotropin-releasing hormone (GnRH) analogues
Endometriosis is a common disorder, characterised by the deposits of endometrial-like tissue outside the uterus. It is an oestrogen dependent condition, that starts after menarche and regresses following the menopause.
Treatments depend upon whether the patient wishes to conceive or not. If the patient is not planning to conceive then treatments include methods that inhibit ovulation (as endometriosis is an oestrogen dependent condition).
The COCP is the first line option and can be used back-to-back with no pill-free interval. Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the Mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation. The copper intrauterine device can make menstrual cycles longer and more painful and would not be a suitable option.
If the above methods fail to improve a patient’s symptoms, then GnRH analogues may be used.
In patients with endometriosis who wish to conceive, then a referral to fertility services is recommended if the couple have not conceived after 6 months of regular unprotected vaginal sexual intercourse. Surgical options such as laparoscopic adhesiolysis may improve fertility rates in patients with mild-moderate disease.
GP notebook. Endometriosis treatments.
A 22-year-old lady, nulligravida presents with chronic pelvic and sacral pain with menstruation. Temperature = 37.2 degrees. On examination her posterior vaginal fornix is tender and there is uterine motion tenderness. Pelvic ultrasound is normal. What is the next diagnostic test?
Endometrial biopsy
Laparoscopy
Hysterosalpingography
CA-125
Serial beta-hCG
Laparoscopy is the gold-standard investigation for patients with suspected endometriosis
The correct answer in this case is laparoscopy. This is because the patient’s presentation of chronic pelvic and sacral pain with menstruation, along with tenderness on examination, is suggestive of endometriosis. Laparoscopy is the gold standard diagnostic test for endometriosis, as it allows for direct visualization and biopsy of suspected lesions.
An endometrial biopsy would not be the most appropriate choice in this situation, as it is primarily used to diagnose endometrial hyperplasia or malignancy. While endometriosis involves ectopic endometrial tissue, an endometrial biopsy would not detect its presence outside of the uterine cavity.
Hysterosalpingography is a radiographic procedure used to evaluate the patency of fallopian tubes and assess the uterine cavity, often in cases of infertility or recurrent pregnancy loss. While it may provide information about tubal obstruction related to endometriosis, it does not directly visualize or diagnose endometriotic lesions.
A CA-125 blood test measures the level of cancer antigen 125 in the bloodstream. Elevated levels can be found in various conditions such as ovarian cancer, endometriosis, and pelvic inflammatory disease (PID). However, CA-125 has limited sensitivity and specificity for diagnosing endometriosis and cannot differentiate between these conditions. Therefore, it is not recommended as a primary diagnostic tool for this patient’s presentation.
Finally, serial beta-hCG measurements are used to monitor early pregnancy progression or detect ectopic pregnancy by assessing changes in human chorionic gonadotropin hormone levels. In this case scenario, there is no mention of pregnancy-related symptoms or concerns; thus, serial beta-hCG testing would not be indicated as a diagnostic tool for her pelvic pain.
A 26-year-old nulliparous Caucasian woman presents to their GP for a follow-up regarding a 3-month history of intermittent severe cramping abdominal and back pain that occurs during and prior to menstruation, which is regular each month. She complains of menorrhagia, stating that she needs to change her pads every 2-3 hours. She is worried these periods are affecting her fertility, as she has been trying to conceive with her long-term boyfriend for over 2 years. A transvaginal ultrasound is completed and reveals an endometrial thickness of 7mm with no other findings.
What is the most likely diagnosis?
Adenomyosis
Endometriosis
Pelvic inflammatory disease
Uterine fibroids
Von Willebrand’s disease
The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility
Endometriosis is correct, as this woman is presenting with symptoms of menorrhagia, dysmenorrhoea, and subfertility. Furthermore, the absence of any findings seen in the transvaginal ultrasound with a normal endometrial thickness does not rule out endometriosis, as findings are often normal in this condition. Endometriosis is the presence of endometrial deposits outside of the endometrium. These deposits are still oestrogen-responsive and therefore can bleed and cause the patient pain, depending on where they are. Bowel and urinary symptoms can sometimes be seen if there are endometrial deposits in these regions. This patient’s lower abdominal and back pain could potentially be due to endometrial deposits located in the peritoneal cavity. For a definitive diagnosis to be made, the gold standard is laparoscopic surgery to visualise these endometrial deposits.
Adenomyosis is incorrect as this condition is typically seen in multiparous women towards the end of their reproductive years. This woman is nulliparous and 26 and therefore does not fit with the typical age group affected by this condition. Furthermore, the transvaginal ultrasound is normal in this patient. Due to the presence of endometrial deposits in the myometrium, transvaginal USS findings in adenomyosis can include an asymmetrical uterus, abnormal myometrial echo texture and myometrial cysts. This patient’s transvaginal USS is normal and therefore makes adenomyosis less likely, though it does not rule it out.
Pelvic inflammatory disease is incorrect, as while you can see abdominal pain in this condition, it also commonly presents with features such as persistent low-grade fever, dyspareunia, vaginal discharge, and dysuria, none of which the patient has. Furthermore, the patient does not fit the demographic typically seen in patients with pelvic inflammatory disease. It is most commonly caused by sexually transmitted organisms (Chlamydia trachomatis., Neisseria gonorrhoea.) and is, therefore, more commonly seen in patients with multiple previous sexual partners. As this patient has a long-term boyfriend, this makes the diagnosis of pelvic inflammatory disease less likely.
Von Willebrand’s disease is incorrect as this is the most commonly inherited bleeding disorder which typically presents with a history of epistaxis and menorrhagia. The patient is presenting with abdominal pain, which would be unexpected. Furthermore, there is only a 3-month history of menorrhagia, whereas a longer history would be expected in this patient due to a bleeding disorder.
Uterine fibroids are incorrect as these would present as a feature on the transvaginal ultrasound scan, which only shows normal findings and a normal endometrial thickness. Furthermore, uterine fibroids are more common in African and Caribbean populations, whereas this woman is Caucasian.
A 25-year-old woman presents to her GP with a continuation of her chronic pelvic pain, which has not been helped with regular paracetamol and ibuprofen use. She continues to suffer from severe pelvic pain before her period, which is irregular. She is not sexually active and does not plan to become pregnant soon. Her main priority is her pain management, and she is open to any treatment. She has a past medical history of migraines with aura, for which she takes sumatriptan and propranolol.
What would be an appropriate next-line treatment?
Bilateral salpingo-oophorectomy with hysterectomy
Combined oral contraceptive pill
GnRH analogue
Oral diclofenac
Progesterone-only pill
If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried
Progesterone-only pill is correct because this woman is presenting with suspected endometriosis, given her severe pelvic pain before the onset of her periods. Her symptoms are not being controlled using regular non-steroidal anti-inflammatory drugs, e.g., ibuprofen and regular paracetamol, therefore, NICE guidelines suggest that if the pain is not controlled with NSAIDs or paracetamol, either the combined oral contraceptive pill (COCP) or a progestogen should be tried. However, this woman has a history of migraines with aura, which means the COCP is contraindicated because of the increased risk of ischaemic stroke in patients who take both COCPs and suffer from migraines with aura. Therefore, because of this contraindication, a progestogen would be the next option for this woman, such as the progesterone-only pill. Other valid progestogen options include the implant, progestogen injectables or a levonorgestrel intrauterine system.
Bilateral salpingo-oophorectomy with hysterectomy is incorrect because this is the last resort for patients with endometriosis and often does not resolve their pain as they can still have endometrial deposits responsive to oestrogen outside of the reproductive tract. This surgery can be offered to patients who have been unresponsive to other therapies as a last resort; however, it would be too early to consider surgery for this patient, who has not tried hormonal options yet.
Combined oral contraceptive pill is incorrect because this is contraindicated in this woman because of her history of migraines with aura.
GnRH analogue is incorrect as this medication can be tried in patients intolerant/unresponsive to first-line hormonal treatment (i.e. progestogen/COCP) or if hormonal treatment is contraindicated. GnRH analogues act to temporarily induce a menopause state and therefore reduce circulating oestrogen levels. Reducing oestrogen levels can cause symptoms to decrease by reducing the response of the ectopic endometrial deposits.
Oral diclofenac is incorrect because analgesia has not worked so far in her management. Diclofenac is another NSAID, and since ibuprofen has already failed to treat this woman’s pain, it is now appropriate to start hormonal treatment. As the COCP is contraindicated for this patient because of her history of migraines with aura, a progestogen, such as the progesterone-only pill, should now be tried.
A 30-year-old woman presents to the gynaecology clinic after having been diagnosed with endometriosis 2 years ago following laparoscopic surgery. She experiences chronic pelvic pain, which worsens during her menstrual cycle, as well as deep dyspareunia.
The patient has had unsuccessful trials of ibuprofen, the progestogen-only pill and the combined oral contraceptive pill. She takes no other medication, has no allergies and has no other medical history. The patient is not currently wishing to become pregnant.
What would be an appropriate next step in treatment?
Insert a copper intrauterine device
Prescribe a regular weak opioid
Prescribe amitriptyline
Trial a gonadotrophin-releasing hormone agonist
Trial an androgen
GnRH analogues may be used in endometriosis if NSAIDs/COCP have not controlled symptoms
Gonadotrophin-releasing hormone agonists (GnRH agonists) may be used as second-line medical management in patients with endometriosis if a combination of non-steroidal anti-inflammatories and the combined oral contraceptive pill have not controlled their symptoms. In this first stage of treatment, patients may also be offered progestogen-only contraception (such as the pill, implant or levonorgestrel intrauterine system), as this patient has. GnRH agonists lead to the down-regulation of GnRH receptors, thus reducing oestrogen (and androgen) production. This reduces the symptoms of endometriosis as oestrogen thickens the uterine lining.
The copper intrauterine device is incorrect. This is because the copper intrauterine device does not contain hormones, so will not prevent the build-up of the uterine lining which is what causes symptoms in endometriosis. Instead, the copper intrauterine device can actually make periods heavier and more painful.
Prescribe a regular weak opioid is incorrect. NICE does not recommend opioids in the management of endometriosis, as endometriosis is a chronic condition and hence there is a high risk of adverse effects and addiction.
Prescribe amitriptyline is incorrect. Whilst this is a medication used in the management of chronic pain, currently, the patient has not explored many of the treatment options for endometriosis. It would be appropriate to work through the pathway of medical (and possibly surgical) endometriosis treatments before prescribing amitriptyline, which comes with side effects and is risky in overdose.
Trial an androgen is incorrect as androgens are third-line treatments, that may be tried for medical management if a GnRH agonist has not been successful. Androgens work by suppressing the hypothalamic-pituitary-androgen axis, leading to a low-oestrogen state. Their use is limited by the side effects of androgen excess.
A 30-year-old woman is brought into the emergency department in intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis. What is the cause of her acute abdomen?
Diverticular disease
Ectopic pregnancy
Endometriosis
Ruptured endometrioma
Toxic megacolon
If an endometrioma ruptures, it will cause sudden intense pain
The history of endometriosis, acute abdomen, and the pelvis filled with fluid all point towards a rupture endometrioma. Diverticular disease is rare in this age group and would not give the clinic picture above. Endometriosis pain is unlikely as she is not currently having her period. Toxic megacolon does not fit the picture. Ectopic pregnancy is an extremely important differential to bear in mind, however as she had her period one week ago, it is not very likely, but it would of course need to be ruled out.
A 22-year-old woman presents to the emergency department with sudden onset right shoulder tip pain and lower abdominal pain, associated with an episode of vaginal bleeding. Her last menstrual period was 10 weeks ago. She is currently sexually active with a long term partner and uses condoms only as a method of contraception.
Urine hCG is reported as elevated and transvaginal ultrasound identifies a foetal pole at the ampulla of the left fallopian tube.
Given the likely diagnosis, which of the following is likely to act as the greatest risk factor?
A history of endometriosis
Maternal age of 22
Previous miscarriage
Previous use of the combined contraceptive pill
Recurrent urinary tract infections (UTIs)
Endometriosis is a risk factor for ectopic pregnancy
Endometriosis is a risk factor for ectopic pregnancy.
Although increasing maternal age is associated with ectopic pregnancy, this only becomes significant above the age of 35.
Previous miscarriage is not necessarily associated with an increased risk of ectopic pregnancy.
Use of the combined contraceptive pill is not a risk factor for ectopic pregnancy.
Recurrent UTIs are only weakly associated with an increased risk of ectopic pregnancy.
A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness.
Which of the following is the most likely diagnosis?
Endometriosis
Fibroid
Interstitial cystitis
Pelvic inflammatory disease
Uterine myoma
The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility
Important for meLess important
This patient has history of menstrual pain (dysmenorrhoea), pain during intercourse (dyspareunia), and subfertility (tried to conceive, but failed). These are classic symptoms of endometriosis. Uterosacral nodularity and tenderness further supports the diagnosis. Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Some patients may also have urinary symptoms due to bladder involvement or adhesions, as seen in this patient.
Uterine leiomyoma (fibroid) is the common pelvic tumor in women. It causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. On examination, there is an enlarged, mobile uterus. Uterosacral nodularity and tenderness on rectal examination is not seen in leiomyoma.
Interstitial cystitis causes urinary frequency and urgency. Patients typically complain of pain with a full bladder that is relieved upon voiding.
The pelvic inflammatory disease presents with fever, nausea, acute pain along with malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.
Uterine myoma often presents with heavy and/or irregular menstrual bleeding. A pelvic exam may show an enlarged, nodular pelvic mass that can vary in size and shape.
Sally is a 34-year-old woman who comes to see you with a 6 month history of chronic pelvic pain and dysmenorrhoea which is starting to affect her daily life particularly at work. On further questioning, she also describes painful bowel movements which start just before her period and continue throughout it.
You suspect endometriosis and Sally asks you how this can be checked for.
What is the gold-standard investigation that can confirm this diagnosis for Sally?
Laparoscopic visualisation of the pelvis
Pelvic MRI scan
Transabdominal ultrasound
Transvaginal ultrasound
Serum CA125 level
Laparoscopy is the gold-standard investigation for patients with suspected endometriosis
NICE guidelines state:
Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis.
Laparoscopy should be considered in women with suspected endometriosis, even if a transvaginal or transabdominal ultrasound is normal.
If a full, systematic laparoscopy is performed and is normal, the woman should be advised that she does not have endometriosis, and alternative management offered.