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ACOG Pub Review > PB#114: Management Of Endometriosis > Flashcards

PB#114: Management Of Endometriosis Flashcards

1
Q

Percentage of reproductive-age pts w/ endo; percentage of infertile pts w/ endo; percentage of chronic pelvic pain pts w/ endo

A

6-10%; 38%; 71-87%

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2
Q

Is there a racial predisposition to endo?

A

No

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3
Q

Familial predisposition to endo

A

7-10-fold increased risk in pts w/ affected 1st degree relative; strong concordance in monozygotic twins

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4
Q

Proposed inheritance pattern for endo

A

Polygenic-multifactorial mechanism (numerous genetic polymorphisms identified)

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5
Q

Most plausible theory for formation of endo

A

Attachment and implantation of endometrial glands and stroma on peritoneum from retrograde menstruation

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6
Q

Alternative theories for endo formation (3)

A

Hematogenous/Lymphatic transport, stem cells from bone marrow, coelomic metaplasia

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7
Q

Key components in development of endo (2)

A

Local overproduction of prostaglandins by increase in COX-2 activity, overproduction of local E2 by increased aromatase activity

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8
Q

Theoretical effect of progesterone resistance in development endo

A

Dampens antiestrogenic effect of progesterone and amplifies local estrogenic effect

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9
Q

Pathophysiologic effect of endometrial lesions

A

Chronic inflammatory disorder, w/ increased numbers of activated macrophages and proinflammatory cytokines in peritoneal fluid that can cause pain/infertility

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10
Q

Most commonly found inflammatory cytokines; their effects

A

TNF-α, IL-1, IL-6, IL-8; associated w/ pain via several mechanisms, including induction of prostaglandins

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11
Q

Peptide highly expressed in endo lesions, especially rectovaginal lesions

A

Nerve growth factor

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12
Q

Neurologic theory behind manifestations of pain associated w/ endo

A

Increased density of nerve fibers in peritoneal endo (especially DIE), close proximity of nerves to peritoneal lesions

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13
Q

Theory that may explain the severe dysmenorrhea and the improvement in endo sxs s/p hyst

A

Changes in innervation of uterus

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14
Q

Sequelae of peritoneal environment w/ high levels of oxidative stress and high concentrations of inflammatory cytokines (2)

A

Sperm dysfunction (including sperm DNA damage), oocyte cytoskeleton function

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15
Q

Infertility lab that is decreased in early stage endo

A

AMH

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16
Q

Endo-related issues that can cause anatomic abnormalities resulting in abnormal tubal function (2)

A

Ovarian cysts (endometriomas), adhesions

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17
Q

Risk factors for endo (5)

A

Early menarche (<11 y/o), shorter cycles (<27 days apart), heavy/prolonged cycles, lower parity, shorter duration of lactation

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18
Q

Lifestyle change associated w/ reduced risk of endo

A

Regular exercise >4 hours/week

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19
Q

Most well-recognized clinical manifestations of endo (5)

A

Dysmenorrhea, CPP, dyspareunia, USL nodularity, adnexal mass (symptomatic or asymptomatic)

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20
Q

Classic sxs associated w/ endo dx (4)

A

Abdominopelvic pain, dysmenorrhea, menorrhagia, dyspareunia

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21
Q

Description of pelvic pain 2/2 endo (3)

A

Secondary dysmenorrhea (w/ pain frequently commencing before onset of menses), deep dyspareunia (exaggerated during menses), sacral backache during menses

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22
Q

Sxs associated w/ endo w/ bowel involvement (5)

A

Perimenstrual tenesmus, diarrhea, constipation, cramping, dyschezia

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23
Q

Sxs associated w/ endo w/ bladder involvement (2)

A

Dysuria, hematuria

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24
Q

Does severity of endo pain correlate w/ stage of disease?

A

No

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25
Q

Does severity of endo pain correlate w/ depth of infiltration of lesions

A

Yes

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26
Q

Most predictable sxs of DIE (2)

A

Dyschezia during menses, severe dyspareunia

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27
Q

How to definitively dx endo

A

Histology of surgically removed lesions

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28
Q

Histology that supports dx of endo lesions

A

Endometrial glands and stroma w/ varying amounts of inflammation and fibrosis

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29
Q

What lab markers, imaging studies, and visual findings at time of laparoscopy are diagnostic for endo?

A

None, none, none (all can be variable and are therefore not diagnostic)

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30
Q

Visual appearance of classical vs nonclassical endo lesions

A

Black powder-burn lesions vs red/white lesions

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31
Q

Where should one look for endo on laparoscopy?

A

Entire pelvis (including under ovaries); include cysto if suspicion for bladder endo

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32
Q

US appearance of endometrioma

A

Ovarian cyst w/ low-level, homogenous internal echoes c/w old blood

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33
Q

Is US generally accurate in differentiating endometriomas from other adnexal masses?

A

Yes, high accuracy

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34
Q

Modality of choice if using imaging to assess for endo/DIE

A

TVUS

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35
Q

Second-line imaging for endo, and when to utilize

A

MRI, reserved for equivocal US results in cases of rectovaginal or bladder endo

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36
Q

How well does ASRM endo classification correlate w/ pain sxs, dyspareunia sxs, infertility?

A

Not well, not well, not well

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37
Q

Value of ASRM endo classification

A

Uniformity of reporting op findings

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38
Q

Are medical suppressive therapies effective for endo-associated infertility?

A

No

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39
Q

Is surgical management effective for endo-associated infertility?

A

Yes (improves pregnancy rates, though magnitude is unclear)

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40
Q

OR, NNT for post-surgery conception in pts w/ endo-associated infertility

A

OR=1.65, NNT=12

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41
Q

Potential surgery that does significantly improve fertility in endo-associated infertility pts

A

Excision of endometrioma

42
Q

Recommended surgical management of endometrioma

A

Excision (more effective than simple drainage and ablation of cyst wall)

43
Q

Risks associated w/ endometrioma (2)

A

Ovarian damage, reduced ovarian reserve

44
Q

After initial unsuccessful surgery for endo-associated infertility, is IVF or reoperation superior re fertility?

A

IVF (unless pain is still a significant issue), as repetitive ovarian surgery has been shown to have a significant negative impact on IVF outcomes

45
Q

Medical management options for endo-associated pain (5)

A

Progestins, danazol, COCs, NSAIDs, GnRH analogs

46
Q

Superior option 6 months s/p tx when comparing COCs to GnRH analogs

A

No significant pain differences

47
Q

Prescribing rec for pts w/ endo-associated pain on COCs

A

Continuous COCs

48
Q

Next step if initial tx fails in pts w/ suspected endo (2 options)

A

Diagnostic lap, empiric tx w/ another med

49
Q

Common non-gyn causes of pelvic pain to r/o (3)

A

IBS, PBS, urinary tract problems

50
Q

Testing to consider to r/o alternative etiologies to endo (4)

A

Pelvic US, CBC, UA, GC/CT

51
Q

First-line tx options for suspected endo-associated pain (2)

A

COCs, NSAIDs

52
Q

Next option if failure to control endo-associated pain w/ first-line therapies

A

3 months course of empiric GnRH analog

53
Q

Sxs that improve w/ empiric GnRH analog therapy (3)

A

Dysmenorrhea, pelvic pain, pelvic tenderness

54
Q

Does response to empiric GnRH analog tx confirm dx of endo?

A

No

55
Q

Progestin-only options for pts w/ endo-associated pain and dysmenorrhea (3)

A

PO progesterone, Depo, LNG-IUD

56
Q

Is bone loss that occurs w/ Depo reversible?

A

Yes, return to pre-tx levels by 12 months

57
Q

Endo pts who should avoid Depo tx

A

Pts interested in timely pregnancy (2/2 delay in resumption of ovulatory cycles)

58
Q

Med category of danazol

A

Androgenic

59
Q

Potential side effects of danazol (3)

A

Acne, hirsutism, myalgias (more severe than other available meds)

60
Q

How long can GnRH agonists be used w/ add-back therapy?

A

1 year

61
Q

Potential side effects of GnRH agonists (3)

A

Hot flushes, vaginal dryness, osteopenia (which may or may not be reversible w/ prolonged use or repeated cycles)

62
Q

Endo sx recurrence rate at 5 years s/p discontinuation in pts w/ advanced disease

A

53-73%

63
Q

Point of using add-back therapy w/ GnRH analog

A

Reduce/eliminate BMD loss

64
Q

First-line add-back regimen

A

PO norethindrone 5mg daily +/- PO conjugated estrogen 0.625mg daily

65
Q

Second-line add-back regimen (for pts who cannot tolerate high-dose progestin)

A

PO Provera 2.5mg daily + transdermal estradiol 25mcg daily

66
Q

Other medication to provide along w/ add-back tx (and dose)

A

Calcium supp (1000mg PO daily)

67
Q

Disadvantages to adding add-back therapy to GnRH analog

A

None (besides cost of additional rx)

68
Q

Additional med to consider for pts who have failed conventional med tx, and why

A

Aromatase inhibitor (ie anastrozole, letrozole), typically prescribed w/ progestin or COC to dampen FSH release and prevent chronic ovarian stim

69
Q

Reoperation rate for endo pts at 2 years postop, 5 years postop, and 7 years postop

A

21%, 47%, 55%

70
Q

One variable that predicts reoperation for endo

A

Younger age at time of index surgery

71
Q

Does uterosacral nerve ablation have demonstrated efficacy for tx of endo-associated pain?

A

No

72
Q

Specific pts who may benefit from presacral neurectomy

A

Pts w/ midline pelvic pain

73
Q

Potential postop side effects of presacral neurectomy (2)

A

Constipation, urinary dysfunction

74
Q

Suspected pathophysiology of endometriomas

A

Progression of endometriosis lesions on ovary that form cystic structures (they are firmly attached to ovary and normal ovarian cortex where oocytes are embedded)

75
Q

Risks associated w/ endometriomas (2 chronic; 2 acute)

A

Pain, infertility; torsion, rupture

76
Q

Is there a risk of malignancy associated w/ endometrioma?

A

Yes, though small

77
Q

Role of CA-125 in evaluating endometrioma

A

May be increased in presence of benign endometrioma, so not useful

78
Q

When should endometriomas be removed surgically?

A

If >3cm (to confirm that cyst is benign), or if symptomatic

79
Q

When should reoperation be considered for pts w/ recurrent endometriomas?

A

On case-by-case basis, 2/2 risk of repeated damage to ovary

80
Q

Preferred approach for endometrioma removal

A

Laparosopic

81
Q

Is preop medical suppressive tx recommended prior to surgery for endo?

A

No

82
Q

Conditions in which postop medical tx may be indicated after surgery for endo (3)

A

Residual disease expected, pain not relieved, in order to extend pain-free interval after surgery

83
Q

Should incidentally identified endo at laparoscopy done for other indications be treated surgically?

A

Individualized basis

84
Q

Percentage of asymptomatic pts being treated for infertility w/ incidentally identified endo

A

20-50%

85
Q

At time of second-look lap for endo in asymptomatic pts, percentage of pts w/ progression, percentage of pts w/ unchanged disease, percentage of pts w/ disease improvement

A

45%, 33%, 22%

86
Q

Possible locations of extrapelvic endo (5)

A

Upper abdomen, diaphragm, abdominal wall (ie umbilicus), perineum (ie episiotomy scar), thorax

87
Q

Non-gyn organs that may exhibit full-thickness endo invasion (4)

A

Rectum, large/small bowel, ureters, bladder

88
Q

Possible sxs of nonreproductive endo (3)

A

Cyclic hematuria, cyclic hematochezia, cyclic hemoptysis

89
Q

First-line med tx for extrapelvic endo

A

GnRH analogs

90
Q

Situation in which surgery is recommended in cases of extrapelvic endo

A

Ureter/bowel obstruction

91
Q

Definitive therapy for tx of endo associated w/ intractable pelvic pain, adnexal masses, and/or multiple previous conservative surgical procedures

A

Hyst + BSO

92
Q

Likelihood of sx recurrence w/ ovarian conservation, likelihood of additional surgical tx w/ ovarian conservation; likelihood of sx recurrence s/p BSO, likelihood of additional surgical tx s/p BSO

A

62%, 31%; 10%, 4%

93
Q

RR for pain recurrence s/p TAH alone compared to TAH/BSO, RR for need for additional surgery s/p TAH alone compared to TAH/BSO

A

RR=6.1, RR=8.1

94
Q

When should ovarian conservation be considered, and what is alternative surgery in such cases?

A

In younger pts w/ normal ovaries, hyst + removal of endo lesions

95
Q

Risk of endo recurrence s/p BSO

A

15%

96
Q

Is endo recurrence s/p BSO affected by use of postop hormone therapy?

A

No, theoretical concerns about hormone therapy stimulating growth of residual ovarian/endometrial tissue and/or estrogen-induced malignant transformation of residual endo implants are not proven

97
Q

Most common site of endo lesion recurrence/persistence s/p hyst + BSO

A

Large/small bowel

98
Q

Pathophysiologic theory for persistence of disease in hypoestrogenic state s/p BSO

A

Local expression of aromatase activity

99
Q

Tx for endo recurrence s/p hyst/BSO

A

Surgery (GnRH analogs in hypoestrogenic state would not be beneficial)

100
Q

Is there an advantage to delaying estrogen tx s/p surgery?

A

No

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