Endometriosis/ Mastitis Flashcards
Endometriosis
general
Common, nonmalignant estrogen-dependent condition in which endometrial glands and stroma implant outside of theuterus
Endometrial implants, nodules, and endometriomas can:
Be highly inflammatory
Occur anywhere in the pelvis, the urinary and gastrointestinal tracts, and distant organs
Epidemiology
Incidencein the general female population: ~10-15%
White > Blacks
Average age at diagnosis: 27 years
Endometriosis
3 types of endometrial tissue
Implants
Small, superficial form of endometrial tissue
Nodules
Larger and more invasive form of endometrial tissue
Endometriomas
Cysts on the ovaries filled with menstrual blood
Also called chocolate cysts
endometriosis
RF
Prolonged endogenous estrogen exposure:
Nulliparity
Early age atmenarche
Latemenopause
Shorter menstrual cycles
Heavy menstrual bleeding
History ofinfertility
History of obstructed outflow (Müllerian anomalies)
Uterine surgery
Low bodymassindex (BMI)
Family historyof endometriosis
endometriosis
Sites of Ectopic Implantation
Ovary (most common site) → endometriomas
Pelvicperitoneum(2nd-most common)
Uterine ligaments (broad, uterosacral)
Within the uterine myometrium →adenomyosis
Rectovaginal septum
Fallopian tubes
Colon,rectum, andappendix
Bladderandureters
Priorsurgical incisionsites
Distant organs (rare):
Lungs
Breast
Bones
Liver,gallbladder,pancreas, andspleen
endometriosis
S/Sx
The location of implants determines the clinical presentation
Symptoms may becyclic, chronic, or progressive
Somepatients are asymptomatic – implants are found incidentally during surgery
Symptoms
Pelvic, abdominal and lower back pain, usually associated with menstruation – 80% of cases
Dysmenorrhea
Dyspareunia
Menorrhagia/Metrorrhagia
Dysuria/Dyschezia
Infertility - 25% of cases
Degrees of Endometriosis
Grade I and II
Grade I (minimal):
Isolated implants appear without adhesions
Grade II (mild)
Endometrial implants are superficial and smaller than 5 cm
May be adhesions to the surface of the peritoneum or ovary, but without affecting other organs
Degrees of Endometriosis
Grade III and IV
Grade III (moderate)
Multiple endometrial nodules with most of them invasive
May be adhesions in the fallopian tubes or ovary
Grade IV (severe)
Ectopic endometrial tissue that is superficial and deep
Formation of endometriomas (chocolate cysts) in the ovaries
endometriosis
PE findings and Dx
Often made clinically based on history and exam findings
Definitive diagnosis can only be made on histologic examination of a surgicalbiopsy
Physical examination findings suggestive of endometriosis
Tenderness on vaginal exam
Visible vaginal endometrial implants
Palpable nodules in the posteriorfornixor rectovaginal septum
Adnexalmass
“Frozenpelvis”:
Immobility of thecervix and/oruteruson bimanual exam
Due to adhesions andscarring
endometriosis
imaging
Transvaginal ultrasound
Endometrioma (chocolatecysts)
Nodules on the rectovaginal septum,abdominal wall, orbladder
Normal-sizeuterus
MRI
May be used if the diagnosis by ultrasound is not clear or before surgery, to determine the exact location and depth of lesions
Laparoscopy
Gold standard for diagnosis
Implant appearance:
Lesions may be red, white, clear, or black-purple
Biopsy for definitive histologic confirmation
Other findings:
Endometriomas
Pelvic adhesions
endometriosis
Pharm Tx
First-line medical management
Non-steroidal anti-inflammatory drugs (NSAIDs)
Hormonal contraceptives
Primary initial treatment
Often given continuously (without placebo days) to completely suppress menstruation
Progestins suppress endometrial growth
Options include:
Combinedoral contraceptivepills (OCPs)
Progesterone-only contraceptive pills (POPs)
Contraceptivepatch
Contraceptivevaginal ring
Levonorgestrel-containingintrauterine devices(IUDs)
Etonogestrel contraceptive implant
Medroxyprogesterone acetate injections
endometriosis
Surgical management
The goal is to provide a definitive histologic diagnosis and resect any visible lesions to treatpain
Ovarian cystectomy for endometriomas
Resection or ablation of the endometrial lesions
Lysis of adhesions
Hysterectomy with or without salpingo-oophorectomy
Reserved forpatientswith moderate-to-severepain
Definitive procedure
Ifovariesremain → persistentestrogenproduction → stimulates any remaining implants → possible to have persistentpain
Supplemental hormone therapy may be considered ifovariesare removed
endometriosis
Complications
Pregnancyimplications
↑ Risk ofpreterm birth
Infertility
Ectopic pregnancy
↑ risk of clear cell epithelialovarian cancer
Intestinal obstructionfrom adhesions
Adenomyosis
general
Common, benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium
One of the structural causes ofabnormal uterine bleeding (AUB) - PALM
May be diffuse or focal
Diffuse → adenomyosis
Focal → adenomyomas
Epidemiology
Occurs in 20%–35% of reproductive-age women
Average age: 40–50 years
Often coexists with other uterine pathology, especially:
Leiomyomas (fibroids)
Endometriosis
Adenomyosis
Clin man
Dysmenorrhea
Abnormal uterine bleeding/heavy menstrual bleeding
Chronic pelvicpain
Dyspareunia
Physical exam may reveal auterusthat is
Symmetrically enlarged
Tender
Boggy (soft)
Mobile (as opposed to fixed, which may occur withendometriosis)
Adenomyosis
Dx and imaging
Based history, exam, and imaging
Transvaginal ultrasound
Preferred imaging modality
Findings suggestive of adenomyosis
Enlargeduterus
Myometrial cysts
Asymmetrical thickening of the myometrium (typically at thefundusor posterior wall)
↑ Myometrial heterogeneity
Loss of a clear endomyometrial border
Dopplerassessment shows ↑ vascularity in the myometrium