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Endometriosis - Dr Deac Pimp

Definition

  • Chronic condition in which endometrial tissue grows outside the uterine cavity.
  • Common sites include fallopian tubes, ovaries, uterosacral ligaments, pouch of Douglas, bladder and rectum
  • Can present in any location
  • Oestrogen-dependent

 

Risk factors

  • Early menarche
  • Late menopause
  • Short menstrual cycles
  • Long menstrual flow
  • Delayed childbearing
  • Vaginal outflow obstruction
  • Infertility
  • Reproductive age: 20s and 30s
  • Genetic factors:
    • Family history

 

Differential diagnoses

  • Physiological bleeding
  • Ectopic pregnancy
  • Miscarriage
  • PID
  • Torsion of ovarian cyst
  • Fibroids
  • Primary dysmenorrhoea
  • Endometrial cancer
  • UTI
  • IBS

 

Epidemiology

  • 10-15% of women of reproductive age
  • Prevalence in infertile women = 25-40%
  • Peak onset in 30s
  • Uncommon under age of 20
  • Takes on average 7.5 years to get a diagnosis from onset of symptoms

 

Aetiology

  • Aetiology is unknown, with several theories
  • Retrograde menstruation:
    • Small amount of backflow of menstrual blood into pelvic cavity is normal, but one theory states that excessive retrograde menstruation may be associated with endometriosis development
  • Genetic component:
    • Family history is a risk factor, and often runs in families
    • No gene has been reliably identified, research is being undertaken with interest in changes to GALT gene
  • Lymphatic or haematogenous spread of endometrial cells (non-malignant)
  • Metaplasia:
    • Metaplasia of cells in affected sites
    • Endometrial lining arises from coelomic epithelium, as do some other structures that can be affected by endometriosis

 

Clinical features

  • Dysmenorrhoea
    • Can be severe
    • Just before or during menstruation
      • If not cyclical in this way, consider an alternative diagnosis
  • Dyspareunia
  • Pelvic pain (may be chronic)
  • Lower back pain
  • Menorrhagia
  • Bloating
  • Constipation
  • Subfertility
  • Cyclical bleeding from outside vagina:
    • Rectal
    • Urethral
    • Haematuria
    • Umbilical
  • Worsening symptoms with age
  • Improvement in symptoms post-menopausal
  • Physical examination is often normal
  • Some posterior fornix tenderness, nodules or blueish haemorrhagic nodules
  • Adnexal mass (from ovarian ‘chocolate cyst’)

 

Pathophysiology

  • Pathogenesis is largely unknown
  • At a basic level, aggregations of endometrial cells are found in extra-uterine locations
  • These shed during menses causing blood loss into local cavity, with associated symptoms including pain

 

Investigations

  • Investigative laparoscopy is gold standard
  • Transvaginal ultrasound to rule out other ovarian or endometrial pathology, eg ovarian endometrioma, fibroids
  • CA-125 can be raised in endometriosis, but limited evidence as a reliable tool
  • MRI
  • Pregnancy test (beta-hCG)
  • Chlamydia NAATs
  • FBC, urinalysis, infection screen if acute

 

Management

  • Pain management
    • NSAIDs can be used for pain relief
    • Creating pseudo-pregnancy or pseudo-menopause  with hormone suppression therapy
      • COCP
      • DEPO
      • IUD (mirena)
      • Danazol (not commonly used now because of androgenic side effects)
      • GnRH analogues/agonists
        • Leuprolide
        • Buserelin
        • Naferelin
        • Histrelin
        • Goserelin
        • Desrolelin
        • Triptorelin
    • Laparoscopic ablation of lesions reduces pain
      • Thermal ablation
      • Laser ablation
      • Excision
      • Ovarian cystectomy
      • Denervation
    • Strip out endometriomata (large cysts of endometriosis)
    • Hysterectomy + salpingo-oophorectomy as last resort
  • Fertility
    • Medical endometriosis treatment should not be used
    • Surgery/ablation of lesions in mild-moderate endometriosis improves fertility
    • Limited evidence for severe endometriosis
    • IVF treatment

 

Prognosis

  • The natural history is highly varied: improves in some patients, remains unchanged in some and worsens in some, in approximately similar proportions
  • 20-50% have recurrence after surgery
  • Increased risk of some types of cancer:
    • Clear cell, low grade serous ovarian cancer
    • Endometrioid invasive ovarian cancer
    • Possibly breast cancer
  • Increased risk of IBD
  • Tubal damage can lead to:
    • Subfertility/infertility
    • Ectopic pregnancy
Endometriosis.docx
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