Endometriosis - GM Flashcards
aetiology
has no single definitive cause
its is likely multifactorial, including
genetic factors
retrograde menstruation
immune system not preventing growth of endometrial tissue outside of the uterus
age of onset
20-40 years
2-10% of all women
more commmon in white/asain ethnicities
definition
endometrium-like tissue growing outside of the uterine cavity
risk factors
early menarche (prolonged exposure to endogenous oestrogen)
short menstrual cycles
late menopause
delayed childbearing
nulliparity
family history
vaginal outflow obstruction
white ethnicity
low body mass index
autoimmune disease
smoking
common locations of endometriotic implants
pelvic organs - ovaries, rectrouterine pouch, fallopian tubes, bladder, cervix
peritoneum
exprepelvic organs - eg. lung, diaphragm - less commonly affected
pathophysiology
endometrial tissue reacts to the hormone cycle and proliferates under the influence of oestrogen
result in increase in inflmmatory and pain mediators
causes anatomical changes eg. adhesions
causes nerve dysfunction
symptoms
chronic pelvic pain lasting six months or longer
dysmenorrhoea: pain often starting days before bleeding
deep dyspareunia, painful intercourse
ovulation pain
non gynae: dysuria, urgency, haematuria and dyschezia (painful bowel movements)
subfertility
clinical examination
abdo palp: tenderness
pelvix exam: reduced organ mobility, tender nodularity in the posterior vaginal fornix, visible vaginal endometriotic lesions, rectrovaginal tenderness
normal pelvic or abdo examination does not exclude endometriosis
differential diagnosis
PID
ectopic pregnancy
torsion of the ovarian cyst
appendicitis
irritable bowel syndrome
primary dysmennorrhea
uterine fibroids
bedside/lab investigations
urine pregnancy tests (FBC, U&Es, CRP)
white cells may be raised in PID
imaging
a transvaginal US may show endometriomas, however a norma scan does not exclude endometriomas
evidence of ovarian cysts or nodules in bladder or rectrovaginal septum
diagnostic laparoscopy
gold standard investigation
invasive procedure
perform if medical management doesn’t work or if the woman has difficulty getting pregnant
or if an US suggests there is deep endometriosis and scar tissue
macroscopic findings of endometrial tissue on ovaries
gunshot lesions or powder burn lesions: black, yellow-brown, or bluish nodules or cystsic structures seen on serosal surfaces of the ovaries and peritoneum
ovarian endometriomas or chocolate cysts: cyst-like structures that contain blood, fluid nd menstrual debris
macroscopic findings on the fallopian tubes
salpingitis isthmica nodosa
nodular types changes resulting in increased risk of sterility/ectopic pregnancy and decreased transmittance
endometriosis stages
stage 1: minimal - patches and scarring
stage 2: mild - adhesions between uterus and rectum
stage 3: moderate - adhesions on the ovaries
stage 4: severe - adhesions to other organs such as the bladder and bowel, changes to the shape of the pelvic organs
classifications don’t always reflect the severity of symptoms
if there are fertility problems, the Endometriosis Fertility Index can b used to help predict pregnancy outcomes following surgery
initial management
NSAIDs/paracetamol
- ibuprofen, mefenamic acid and naproxen
synthetric androgens
hormonal treatment (COCP or progesterone)
NSAIDs alone if pregnancy desired
GnRH agonists for severe symptoms
symptoms may also improve after pregnancy as well as in menopause
non-pharm management
pelvic floor physiotherapy, psychology CBT, diet and exercise
how does the COCP help
take continuously and skip the sugar pills
stops periods, may reduce pain, may slow the progression of endometriosis
first line surgical management
laparoscopic surgery through belly button
excision or ablation of endometriosis, adhesiolysis and removal of endometriomas can be offered because this may improve chances of spontaneous pregnancy
second line surgical therapy
if fertility is not a priority:
hysterectomy may be performed laparoscopically (with or without salpingo-oophorectomy)
complications of endometriosis
infertility
endometriomas (cysts containing blood and endometriosis-like tissue) which may rupture or affect fertility
adhesions: secondary to endometriosis or surgery
bladder obstruction secondary to the adhesions
haematuria/rectal bleeding
anaemia
ectopic pregnancy - endometriosis in the uterotubal junctions inhibits implantation of the zygote
adenomyosis (differential)
endomterial tissue in the myometrium due to hyperplasia of the endometrial basal layer
infertility with endometriosis
30-50% of women with endo find it hard to get pregnant
may be due to things like scarring of the fallopian tubes and ovaries or changes to pelvic organs
endometriosis fertility index
to help predict natural or assisted pregnency after surgery
does IVF make endometriosis worse
there is no evidence to suggest this
pregnancy does not cure endometriosis, but symptoms may improve because you dont have periods during pregnancy
why does exercise help
reduces inflammation
relaxes pelvic floor muscles
improve range of movement in hips and pelvic area
help with constipation, bloating and bowel pain
