Pelvic Pain and Dyspareunia - Endometriosis

Question 1

What is Endometriosis?

Answer 1

Ectopic endometrial tissue outside the uterus.

Question 2

What are Endometriomas?
What is a Chocolate Cyst?
What is Adenomyosis?

Answer 2

Endometrioma - Lump of Endometrial Tissue outside the Uterus.
Chocolate Cyst - Endometrioma in an Ovary.
Adenomyosis - Endometrial Tissue within the Myometrium.

Question 3

Aetiology of Endometriosis : Theories (4).

Answer 3

1. Retrograde Menstruation - Endometrial Lining flows backwards through the Fallopian tubes and out into the Pelvis and Peritoneum.
2. Embryonic Cells (destined to become Endometrial Tissue) remain in ectopic sites.
3. Spread via Lymphatics.
4. Metaplasia of Ectopic Cells.

Question 4

Clinical Features of Endometriosis.

Answer 4

1. Cyclical Dull/Heavy/Burning Abdominal/Pelvic Pain.
2. DEEP Dyspareunia.
3. Dysmenorrhoea (Secondary).
4. Infertility.
5. Cyclical Bleeding from Ectopic Sites e.g. Haematuria.
6. Cyclical Effect on Urinary/Bowel Symptoms.

Question 5

What causes the Pelvic Pain?

Answer 5

Ectopic cells respond to hormones in the same way as endometrial tissue in the uterus; shedding its lining, bleeding causing irritation and inflammation of surrounding tissues.

Question 6

What can cause Blood in Urine/Stools?

Answer 6

Deposits of Endometriosis in Bowel/Bladder.

Question 7

What can cause the Cyclical Pain to become Chronic and Non-Cyclical?

Answer 7

SHARP, STABBING, PULLING (with Nausea) : localised bleeding and inflammation leads to adhesions.

Question 8

What can cause reduced fertility? (2)

Answer 8

1. Adhesions around Ovaries and Fallopian tubes.

2. Chocolate Cysts.

Question 9

Investigations of Endometriosis.

Answer 9

1. Gold Standard : Laparoscopic Surgery.
2. Definitive Diagnosis : Biopsy from Laparoscopy.
3. Pelvic US - LARGE Endometriomas or Chocolate Cysts (refer to Gynaecology for Laparoscopy).

Question 10

Clinical Examination of Endometriosis (3).

Answer 10

1. Vagina + Speculum : Endometrial Tissue Visible in Vagina (usually Posterior Fornix).
2. Fixed Cervix on Bimanual Examination.
3. Tenderness in Vagina, Cervix and Adnexa.

Question 11

What is the added benefit of a Laparoscopy?

Answer 11

The surgeon can remove deposits of endometriosis and potentially improve symptoms.

Question 12

Staging of Endometriosis (4).

Answer 12

ASRM :

1. Small, Superficial Lesions.
2. Mild Deeper Lesions.
3. Deeper Lesions (Ovaries) and Mild Adhesions.
4. Deep and Larger Lesions (Ovaries) and Extensive Adhesions.

Question 13

Management of Endometriosis (3).

Answer 13

1. Initial Management.
2. Hormonal Management.
3. Surgical Management.

Question 14

What does Initial Management involve? (3)

Answer 14

1. Establish Diagnosis.
2. Patient Education.
3. Analgesia : NSAIDs and paracetamol (1st Line).

Question 15

What does Hormonal Management involve? (4)

Answer 15

1. COCP (without Pill-Free Period).
2. PO Pill/Implant/Injection.
3. Mirena Coil.
4. GnRH Agonists.

Question 16

What does Surgical Management involve?

Answer 16

1. Laparoscopic Surgery : Excise/Ablate Endometrial Tissues and Adhesiolysis.
2. Hysterectomy and Bilateral Salpingo-oopherectomy : removal of ovaries induces the menopause.

Question 17

Which of the management methods may improve fertility?

Answer 17

Laparoscopic surgery.

Question 18

How does Hormonal Management reduce Cyclical Pain?

Answer 18

1. Contraceptives stop ovulation and reduce endometrial thickening.
2. GnRH Agonists induce a menopause-like state to shut down the ovaries temporarily.