Endometriosis - GM

Question 1

aetiology

Answer 1

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

Question 2

age of onset

Answer 2

20-40 years
2-10% of all women
more commmon in white/asain ethnicities

Question 3

definition

Answer 3

endometrium-like tissue growing outside of the uterine cavity

Question 4

risk factors

Answer 4

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

Question 5

common locations of endometriotic implants

Answer 5

pelvic organs - ovaries, rectrouterine pouch, fallopian tubes, bladder, cervix
peritoneum
exprepelvic organs - eg. lung, diaphragm - less commonly affected

Question 6

pathophysiology

Answer 6

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

Question 7

symptoms

Answer 7

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

Question 8

clinical examination

Answer 8

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

Question 9

differential diagnosis

Answer 9

PID
ectopic pregnancy
torsion of the ovarian cyst
appendicitis
irritable bowel syndrome
primary dysmennorrhea
uterine fibroids

Question 10

bedside/lab investigations

Answer 10

urine pregnancy tests (FBC, U&Es, CRP)
white cells may be raised in PID

Question 11

imaging

Answer 11

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

Question 12

diagnostic laparoscopy

Answer 12

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

Question 13

macroscopic findings of endometrial tissue on ovaries

Answer 13

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

Question 14

macroscopic findings on the fallopian tubes

Answer 14

salpingitis isthmica nodosa
nodular types changes resulting in increased risk of sterility/ectopic pregnancy and decreased transmittance

Question 15

endometriosis stages

Answer 15

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

Question 16

initial management

Answer 16

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

Question 17

non-pharm management

Answer 17

pelvic floor physiotherapy, psychology CBT, diet and exercise

Question 18

how does the COCP help

Answer 18

take continuously and skip the sugar pills
stops periods, may reduce pain, may slow the progression of endometriosis

Question 19

first line surgical management

Answer 19

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

Question 20

second line surgical therapy

Answer 20

if fertility is not a priority:
hysterectomy may be performed laparoscopically (with or without salpingo-oophorectomy)

Question 21

complications of endometriosis

Answer 21

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

Question 22

adenomyosis (differential)

Answer 22

endomterial tissue in the myometrium due to hyperplasia of the endometrial basal layer

Question 23

infertility with endometriosis

Answer 23

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

Question 24

endometriosis fertility index

Answer 24

to help predict natural or assisted pregnency after surgery

Question 25

does IVF make endometriosis worse

Answer 25

there is no evidence to suggest this
pregnancy does not cure endometriosis, but symptoms may improve because you dont have periods during pregnancy

Question 26

why does exercise help

Answer 26

reduces inflammation
relaxes pelvic floor muscles
improve range of movement in hips and pelvic area
help with constipation, bloating and bowel pain