Pelvic Pathology

Question 1

Endometriosis Management

Answer 1

> 50% women regress
Asymptomatic patients do not require Tx

Medical
NSAIDs

Hormonal Therapy
COCP (Tricycling regimen)
Not suitable for older women, smokers etc,

Cyclical or continuous progesterones
SE: weight gain, fluid retention, erratic bleeding, PMS

GnRH analogues
Induce temporary menopausal state
Reversible bone demineralisation limits therapy to 6m, (2 years with add-back HRT)

Danazol and Gestrinone have androgenic effects but are rarely used

Surgical
Laparoscopic removal/destruction of endometrial tissue
Can improve conception rates

Radical surgery involves dissection of adhesion and removal of endometriomas (can do TAH + BSO)

Darin and remove chocolate cyst

Risk of damaging bowel, bladder, BVs and ureters

Question 2

Chronic Pelvic Pain

Answer 2

Intermittent or constant pain in lower abdomen or pelvis for >6m duration
Not occurring exclusively with menstruation or intercourse

Ix: TVUS, MRI, laparoscopy

Varies considerably over menstrual cycle may be due to hormonally driven gynaecological conditions:
endometriosis or adenomyosis
 Postmenopausal pain is rare – likely to be oestrogen driven process
 Ovarian tissue can be trapped in adhesions  cyclical pain
o Tx via oophorectomy or adhesiolysis
 Symptoms suggestive of IBS or interstitial cystitis are often present in women with CPP
o Primary cause or component of pain
 Psychological features important – assess sleep and depression
 Hx may feature childhood/ongoing sexual and/or physical abuse
 Pelvic congestion syndrome
o Venous congestion to pelvis  chronic pain
o Causes myofascial syndrome
 Pain originates in muscle trigger points or trapped nerves

Mx
 IBS: dietary changes and antispasmodics
 Appropriate analgesia
 Cyclical pain: COCP, GnRH analogue + add-back HRT for 3-6m
 Then diagnostic laparaoscopy
 Counselling and psychotherapy including relaxation techniques, sex therapy, diet and exercise
 Tx of pain empirically
o Amitriptyline or gabapentin may be used

Question 3

Endometriosis Grading System

Answer 3

American Fertility Society - Points Score 1-4

1: minimal - 4:severe based on position of endometriosis deposits and adhesion

Symptoms DO NOT correlate with severity of disease

Question 4

Presenting Features of Endometriosis

Answer 4

Chronic pelvic pain
Usually cyclical pain - preceding menstruation 
Deep dyspareunia
Sub-fertility 
Pain passing stool
Menstrual problems

Cyclical haematuria, rectal bleeding, or bleeding from umbilicus –> severe and extensive disease