Endometriosis

Question 1

Define endometriosis

Answer 1

The growth of endometrial tissue (glands and stroma) outside the endometrium.
Most commonly in the ovaries fallopian tubes and broad ligaments.
(not the myometrium -> this is adenomyosis)

Question 2

What is the epidemiology of endometriosis?

Answer 2

Affects 1 in 10 women of reproductive years
Typically diagnosed around age 30yrs

Question 3

What are the risk factors for endometriosis?

Answer 3

Early first menses
Short cycles
Heavy menses - longer than 7 days
FH/Genetics
Low body fat

Question 4

What is the key pathology underpinning endometriosis?

Answer 4

Oestrogen dependent tissue -> responses to fluctuations in hormones will grow and mense

1. Retrograde menstruation
2. Coelomic Metasplasia -> peritoneal mesothelial cells differentiate into endometrial tissue
3. Lymphatic and vascular dissemination
4. Combination of genetic and environmental factors

Question 5

What is the key presentation of endometriosis?

Answer 5

Menorrhagia
Dysmenorrhia (abdo and pelvic pain >6m - worse during menses)
Anaemic -> tired, SOB,
Dyspareunia
Subfertility/infertility
Change in bowel habits -> pain on defecation
Dysuria and haematuria

Question 6

What examinations should be done for endometriosis?

Answer 6

Transabdo US -> chocolate cysts (endometriomas), adhesions
Transvaginal US -> as above
Speculum and bimanual -> painful, tender in fornix, reduced organ mobility, large endometriomas

Question 7

What investigations should be done for endometriosis?

Answer 7

Bedside: Abdo exam, TV US (first line), bimanual
Bloods: CA-125 (rule out ovarian cancer), FBC, U&E, LFTs, TFT, Haematinics, Group and save, cross match, Coag, Oes, Test, FSH, LH, SHBG
Imaging: MRI pelvis (for deep endometriosis), diagnostic laporascopy,

Question 8

What is the golden standard investigation for endometriosis?

Answer 8

Diagnostic laproscopy

Question 9

What is the key treatment for endometriosis?

Answer 9

COCP, POP, PO -> reduce pain and menorrhagia
Pain specialist/management -> initially 3m paracetamol +/- NSAID
Surgical -> resecetion -> this is the only treatment that improves fertility
Severe -> hysterectomy with bilateral oophorectomy.

Question 10

What are the different stages of endometriosis?

Answer 10

1 - superficial, single or both ovary
2 - mild but deeper than 1
3 - deep, spread to multiple organs within the pelvis including ovaries and mild adhesions
4 - deep and large lesions affecting ovaries with extensive adhesions

Question 11

What are some key complications of endometriosis?

Answer 11

Increased risk of ovarian cancer
Increased risk of an ectopic pregnancy
Sub-fertility
Inc risk of MH such as depression due to chronic pain.

Question 12

Why is endometriosis problematic?

Answer 12

Triggers local inflammation (cytokines, GF, macrophages) this promotes angiogenesis (high VEGF), fibrosis and adhesions (increased MMPS and integrins).
Ectopic tissue produce oestrogens sustaining own growth, norm progesterone resistant.
Tissue produce PG -> leads to dysmenorrhoea and pain through uterine contractions
Ectopic tissue will grow and shred, tissue can collect at the bottom of the peritoneal cavity.

Question 13

When does endometriosis require referral to secondary care services?

Answer 13

Signs of cysts
Failure to manage in primary care -> particularly if fertility concerns
Persistent and severe
Bowel/bladder symptoms

Question 14

What anatomical structure does endometriosis tissue tend to gather when shed?

Answer 14

The pouch of douglas