Endometriosis

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Definition

-  Ectopic endometrial cells (outside of endometrial cavity)

-  Continue to respond to hormones

-  Produces chronic inflammation

 

Features

-  Idiopathic

-  Retrograde menstrual flow

-  ? differentiation of coelomic membrane remnants (Mullerian rests)

-  Genetic 52% of risk

-  Prevelance 6-8%

-  25% women undergoing Sx for pelvic pain

-  20% women undergoing Sx for infertility

-  Typically seen women 25-30 years

-  May start in 10-20s

-  Dx often delayed

-  Extrapelvic sites seen in women 35-40 years

-  Second most common reason for surgery in young women

-  Sites

-  Pelivc

-  Ovaries, fallopian tubes, vagina, cervix, uterosacral ligaments, rectovaginal septum

-  Other

-  GIT most common extrapelvic site: gall bladder, stomach

-  Laparotomy scars, pleura, lungs, diaphragm, kidneys, spleen, nasal mucosa, spinal canal, breast

 

Associated S/S

-  Most commonly asymptomatic

-  Dysmenorrhoea

-  May be at any time during month

-  Heavy menstrual bleeds, dyspareunia

-  Pelvic pain & tenderness

-  Cause of 15% of pelvic pain in women

-  Tender nodular mass along thickened uterosacral ligament, post. uterus or post. cul de sac

-  Sharp stabbing, burning pains

-  Bowel obstruction, rectal bleeding, constipation

-  Dyschezia, bloating, nausea, vomiting, inguinal pain

-  Dysuria, polyuria

-  Infertility

-  Fatigue, malaise

-  S/S improve whilst pregnant & after menopause

-  Can recur postpartum or on HRT

-  Endomterioma

 

DDx

-  IBS

 

Ix

-  FBE

-  RBC: anaemia

-  WBC may indicate PID instead

-  +/- Dipstick & MSU for MCS: exclude UTI

-  +/- Endocervical MCS: STI, PID

-  +/- Beta hCG: exclude pregnancy

-  US (TV or TA): endometrioma (chocolate cysts)

-  +/- MRI

-  Abdo exam

-  VE + Bimanual exam: tethered uterus, adnexal mass, nodules

-  Laparoscopy w biopsy

-  Only definitive Dx

-  97% sens, 77% sens

-  Lesions may be clear & not always brown

 

Mx

-  Analgesia

-  Regular Paracetamol + NSAIDs

-  PRN opiods: Tramadol..

-  Hormonal

-  Does not improve fertility

-  COC: cyclical, tricyclical or continous

-  Progestins: Medroxyprogesterone

-  Androgens: Danazol

-  Masculinising effects, mood swings, bloating

-  GnRH analogues w/wo HRT

-  Risk of osteoporosis

-  Sx

-  Improves fertility in mild disease

-  Endometrioma should be removed prior to fertility Mx

-  May recur

-  Conservative

-  Laparoscopy w lesion lysis/ablation

-  Definitive

-  Total Abdominal Hysterectomy w Bilateral Salpingo-oopherectomy

-  S/S may persist (not all ectopic tissue removed)