Endometriosis + Chronic Pelvic Pain

Question 1

Endometriosis Ix

Answer 1

Bimanual (masses, ?RV uterus)
Speculum
TVUSS (?endometrioma)
Diagonstic laparoscopy

Question 2

Pelvic pain in Endometriosis controlled by?

Answer 2

Analgesia

Hormonal ovarian supression

Question 3

Indication for medical mx of endometriosis

Answer 3

Clinical examination/TVUSS are normal
No need for laparoscopy
If no symptom relief after 3-6m then laparoscopy

Question 4

Common comorbidity in endometriosis

Answer 4

IBS + Constipation

up to 80%

Question 5

Endometriosis curable?

Answer 5

No - recurs throughout reproductive life

Question 6

Things to consider with endometriosis Mx

Answer 6

Age
Symptoms
Extent of disease
Desire for children

Question 7

Medical Mx of Endometriosis

Answer 7

1. Analgesia (NSAIDS, avoid opiates (constipation/IBS)
2. COCP (regulation, reduce pain, anovulation an option)
3. Progestogens (induce anovulation in pts w/CI to COCP)
4. GnRH agonist: Leuprorelin
5. Other Hormonal: aromatase inhib (research only)

Question 8

Which progestogen to use in endometriosis?

Answer 8

Depot-medroxyprogesterone acetate (Depo provera)

LNG-IUS

Question 9

GnRH Analogue in endometriosis?

Answer 9

Leuprorelin
Slow release depot (>1m)
Don’t use >6m (osteoporosis)
Alternative: intranasal soray (multiple/day)

Question 10

Surgical Mx of Endometriosis fertility sparing

Answer 10

• Laparoscopically (most)
  
  • Chocolate cysts drained only (to protect ovary)
  • Superficial peritoneal endom. ablated/excised (diathermy)
  • Adhesiolysis
  • Risk of recurrence up to 30% so long term medical mx often necessary and started after surgery

Question 11

Surgical Mx of Endometriosis non-fertility sparing

Answer 11

Hysterectomy + Oopherectomy:

• includes removal of all visible endometriosis lesions
• consider in all women w/completed family
• not a 100% guarantee of cure
• HRT

Question 12

HRT after hysterectomy and oopherectomy for endometriosis

Answer 12

• Oestrogen only HRT immediately
• can wait for 6mo to prevent stimulating leftover tissue
• Combined HRT if reactivation

Question 13

Fertility after Management for Endometriosis?

Answer 13

• Improved if fertility sparing (removal of cysts)
• Infertile if Hysterectomy +BSO
• Drug therapy has no impact

Question 14

PACES Counselling of Endmoetriosis

Answer 14

RF: Early menarche, FHx, nullip, >5 menstruation, short cycle (<28d)
Dx: womb tissue outside of womb
Epi: v common (10% repro age)
Mx:
 - C: NSAIDs
 - M: COCP, LNG-IUS, Prog.
 - S: Laparoscopy/Hysterectomy
NB. Explain fertility

Question 15

Chronic Pelvic Pain Ix

Answer 15

1. Hx: Pattern/pain, associations (psych, bladder, bowel), effect of movement/posture
2. Ex: Abdo+pelvic for mass/pn
3. Swab: STI screen
4. Pelvic USS: if mass suspected
   Urinalysis, MC+S
5. MRI
6. Laparoscopy (gold standdard) if mass/endometriosis/adhesions suspected

Question 16

DDx Pelvic pain on USS

Answer 16

Ovarian cyst
Endometrioma
Hydrosalpinges
Tubo-ovarian abcess
Uterine path (adenomyosis/fibroids)

Question 17

MRI in Chronic Pelvic Pain

Answer 17

Visualise pelvic masses or deep infiltrating endometriosis

Question 18

Mx of Chronic Pelvic Pain

Answer 18

Lifetyle
Analgesia
3-6m hormal ovarian suppression if cyclical pain
If fails -> laparoscopy
Surgery for structural path
Referral if non-gynae

Question 19

Specific Treatments in chronic pelvic pain

Answer 19

• Interstitial cystitis: avoid trigger, amitriptyline/gabapentin
• Fibromyalgia/Levator ani syndrome: NSAIDs/PT
• Vulvodynia: topical anaesthetic, amitriptyline/gabapentin