Endometrosis and Dysmenorrhoea

Question 1

What are the primary and secondary causes of dysmenorrhoea. What are its general characteristics?

Answer 1

• Primary (unknown, possibly PG-related)
• Secondary: endometriosis, adenomyosis, intra-cavity mass
• Generally suprapubic pain during menstruation, can radiate to thighs/low back/iliac fossae

Question 2

Describe some causes of dyspareunia

Answer 2

• Superficial: thrush, skin conditions, vestibulodynia
• Deep: endometriosis, adenomyosis, adhesions, ovarian cysts, neoplasms
• Midway: pelvic floor pathology e.g. spasm

Question 3

Describe the different ways a woman with endometriosis might present

Answer 3

• Cyclical pain: dysmenorrhoea, dyschezia, dysuria during period, or non-menstrual pain worse during period
• Provoked pain: dyspareunia, pain inserting tampons/at vaginal entrance
• Infertility
• Incidental finding

Question 4

What are the examination finding you may elicit in a patient with endometriosis?

Answer 4

• Examination findings: lower abdominal tenderness, PV tenderness, palpable vaginal nodule, fixed uterus

Question 5

How is endometriosis diagnosed?

Answer 5

• Clinical +/- ultrasound, laparoscopy (latter gold standard)

Question 6

How can a patient with endometriosis be managed?

Answer 6

• Presentation-dependent
  
  • Pain: analgesics, hormonal suppressants (OCP, depo, GnRH analogues), surgical ablation/resection
    
    • Treatments may not cure pain
  • Infertility: surgery (removal of endometriomas, hydrosalpinges), early move to IVF and planning pregnancies sooner

Question 7

What is the typical presentation of someone with adenomyosis? How is it diagnosed?

Answer 7

• Menorrhagia, dysmenorrhoea
• Bulky, tender uterus on bimanual examination
• Ultrasound, histology (latter gold standard)

Question 8

How is a patient with adenomyosis managed?

Answer 8

• Analgesics, hormonal suppressants, surgical ablation/resection

Question 9

What is primary dysmenorrhoea? Its natural history? How is it managed?

Answer 9

• Definition: absence of known pathology
• Aetiology: possibly prostaglandin-caused myometrial “angina”-like cramps
• Epidemiology: reduces with increasing age and parity, OCP usage
• Management: NSAIDs (decrease PGs), hormonal suppression, hysterectomy