endometrial tissue is present outside the uterine cavity

causing cyclic sypmtoms

reduced fertility

‘working diagnosis’ - patient’s symptoms + evaluation of risk-factors

laparoscopy == definitive

diagnosis

• presence of endometrial tissue, glands and stroma outside uterine cavity

• 3 distinct manifestations

• endometrial implantation on peritoneum causing lesions and endometriomas

• ovarian cysts (chocolate cysts)

• endometriotic nodules in tissue betweenrectum and vagina

• clinical presentation varies widely

  • aysmptomatic - 1/3

  • chronic pelvic pain

  • dysmenorrhoea

  • dyspareunia

  • painful defecation

• hormonally responsive

  • symptoms worse around menstruation

  • during peroid of anovulation:

    • pregnancy

    • lactation

    • menopause

    • hormone

    • sympotms decreased or eliminated

• significant effect on female infertility

• 5-10% reproductive age

• 50% reduced fertility

• 70-90% chronic pelvic pain

• peak incidence 25-30yo

common symptoms

• severe dysmenorrhea

• bloating

• lethargy

• pelvic pain

• constipation

• lower abdominal or back pain

• dyspareunia

• painful defecation

• infertility

• heavy menstruation/pre-menstrual spotting

• cyclic pain upon urination and urinary frequency

• pain during episode

examination

• normal

• diffuse pelvic or posterior fornix tenderness/palpable pelvic mass sometimes present

• uterosacral ligmanet nodules may be palpable

• exam to rule out other:

  • sti

  • cervicitis

  • abnormal vaginal discharge

  • cervical excitiation

  • adnexal masses

investigation

• imaging not usually helpful

• TV USS

  • cysts/nodules are small or not on or near nodules then imaging not of any use

• bloods

  • fbc

  • ferritiin

  • TSH

Cause

• unknown

• retrograde menstruation = central to development of endometriosis

  • in 90% of women

  • only portion go onto having endometriotic lesions and endometriomas

Risk factors

• first degree female relative

• short menstrual cycles (\<27d)

• long menstruation (>5d)

• low bmi

• early menarche

• nulliparity

• Mullerian anomolies

• Outflow obstructions

  • cervical stenosis, transverse vaginal septum, imperforate hymen

Differential diagnosis

• Adenyosis

  • endometrial tissue present within muscles of uterus

  • women in older age group compared to endometriosis (35-50yo)

  • symptomatically identircal to endometriosis

  • usually only distinguished after laparoscopy

  • commonly co-exists with endometriosis

• Uterine fibroids

• Irritable bowel syndrome

  • less likely to present with painful defecation

• Colon/ovarian cancer

Referal

• Endometriosis stonfly suspected and immediate ferility is desired

• Trial treatment with analgesia and hormaonal medicine is unsuccessful

• Patient has persistent, constant pelvic pain, signifiant bowel/bladder pain

• Pelvic mass especially if tender found on examination

• pain or other symptoms that require signifiant amound of time off work or school

Management

Medical mangaement

• relieves symptoms in 80-90% of cases

• Analgesia

  • NSAIDs

    • all have similar efficacy

  • Avoid opiates

• Hormonal

  • Combined contraceptive

    • who don’t wish to conceive in near future

    • tricycle - 6mo cylcles

  • Progestin hormon treatment

    • high dose

      • medroxyprogesterone 10-100mg/day

        • 10mg tds 90d

        • day1 cycle

      • norethisterone 10-45mg/day

        • 5mg bd for 6/12

        • start d1-5 of cycle

      • suppress HPO

        • inhibit ovulation

      • also direct effect on endometrium

        • atrophy both normal endometrium and endometriotic lesions

      • generally well tolerated

    • L - IUS

      • effective even after 3 years of use

  • Gonadotropin releaing hormone analogues

    • induce medical menopause

    • secondary care

    • implant or injection

    • associated with BMD decrease

    • add back therapy

      • concurrently add progestin + bisphosphonate or oestrogen

Fertility (infertility)

• not well understood

• inflammation, structural abnormalties, endometriomas of ovaries, alterations spem-oocyte interaction, decreased endometrial receptivity

• not possible to differentiate between women with endo who will experience decrease fertility those who will retain normal levels of fertility

• Surgey = most common therapy

• Assited fertility treatments likley to be beneficial

• Cochrane review: no increase in fertility after treatmetn with hormonal medicines

• medroxyprogesterone and some androgenic may have lasting effects of ovulation suppression

  • not more than a few months

surgical

• highly effetive for symptoms and pain reduciton

• increase fertility in sub-fertile women

• recurrence rates are high

  • 50% redevelop symptoms within 5yrs of surgery

• two cateogries

  • suregry with preservation of fertility

  • surgery if fertility not desired

complications

• common

• adhesion formation

  • inflammation of peritoneal surfaces

  • increased by surgical intervention

  • sequelae

    • pain

    • structural changes to pelvic and reproductive organs

    • bowel obstruction

• ovarian failure

  • 2.4% women after ablation of ovarian endometriomas

  • even with less aggressive surgery