(gynae) Endometrieosis

Question 1

What is endometriosis

Answer 1

Presence of endometrial tissue outside the uterus

Nb: the ectopic endometrial glands and stroma are functional and active

Question 2

Clinical features of endometriosis

Answer 2

Up to one-third of patients are asymptomatic. [1]

Chronic pelvic pain that worsens before the onset of menses.
- may be expressed as lower abd pain, back pain, loin pain, pain on exercise, pain during micturition

Uterosacral tenderness, uterosacral nodularity [2]

Dysmenorrhea- often occurs with pelvic pain; a dragging aching pain exacerbated by menses

Pre- or postmenstrual bleeding(menorrhagia- bleeding that lasts more than 7 days or heavy bleeding)

Dyspareunia

Infertility [3]

Dyschezia

Question 3

Examination findings of endometriosis

Answer 3

Abd exam: tender lesion in a C-section or laporatomy scar

Speculum: bluish or clear red cysts/nodules mostly seen in posterior fornix and cervix

Bimanual exam: pelvic tenderness, tender uterosacral ligaments, enlarged ovaries

Detection of nodules improved by doing exam during menstration

May have normal exam

Question 4

Investigation of choice for endometriosis

Answer 4

Laparoscopy: gold standard
Direct visualisation of endometriotic lesions and presence of adhesions
Allows for biopsy to be done
Allows for classification as level of pain cannot be used to judge disease severity

Others:
Imaging namely ultrasound and mri; user dependent

Serum ca-125 markers usually elevated in ovarian malignancy but can be reported in association with endometriosis

Question 5

Tx of endometriosis

Answer 5

Medical therapy
Mild to moderate pelvic pain without complications
Empirical medical therapy with NSAIDs and continuous hormonal contraceptives
NSAIDs alone if pregnancy is desired
Synthetic androgens (e.g., danazol)
Severe symptoms
GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs
Surgical therapy
First-line: laparoscopic excision and ablation of endometrial implants
To confirm the diagnosis and exclude malignancy (see “diagnostics” above)
If there is a lack of response to medical therapy
Treat expanding endometriomas and complications (e.g., bowel/bladder obstruction, rupture of endometrioma, infertility)
Second-line: open surgery with hysterectomy with or without bilateral salpingo-oophorectomy
Treatment-resistant symptoms
No desire to bear additional children