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Endometriosis (Clinical presentation (Pelvic pain (Radiation Nil, Timing…
Endometriosis
Clinical
presentation
Pelvic pain
Radiation
Nil
Timing
Cyclic or constant
Character
Dyspareunia (deep; indicates uterosacral ligament involvement)
Dysmenorrhoea (pain during menses)
Dysuria (pain on urination)
Dyschezia (pain on passing stool)
Onset
Often insidious, chronic
Associated symptoms
Subfertility, dysuria, dyschezia
Site
Lower abodomen
Exacerbating/relieving factors
Exacerbating: menses
Relieving: ?analgesics
Severity
Variable, and does not relate to
severity of the disease
Subfertility
Urinary symptoms
Dysuria
Cyclical haematuria
Bowel symptoms
Dyschezia
Cyclical PR bleeds
Asymptomatic
Differentials
Neoplastic
Fibroids
Polyps
Cervical Ca
Functional
IBS
Infection/inflammation
Adenomyosis
PID
UTI
Trauma
Adhesions
Autoimmune
IBD
Pathophysiology
Development
Retrograde menstruation, with adherance, invasion and growth of ectopic endometrial tissue
Also mesothelial cell metaplasia and impaired immunity
Unclear
Spread
Systemic and lymphatic spread, with pain and cyclical bleeds at site
Common: ovaries, pouch of Douglas, broad/uterosacral ligaments, bladder
Rare: lung, brain, muscle, eye
Histology
Peritoneal lesions: small, red/white/brown/black, vesicular/cystic/petechial
Ovarian lesions: larger endometriomas filled with old blood/tissue (chocolate cysts), associated fibrosis and adhesions
Rectovaginal lesions: solid, fibrotic
Epidemiology
10% females
~30% undergoing subfertility investigation
~30% with chronic pelvic pain and
~50% with dysmenorrhoea
Onset 30-40y
Diagnosis
Examination
Pelvic
Adnexal masses (endometriomas), adnexal tenderness (uterosacral ligament lesions), fixed uterus,
palpable nodules on uterosacral ligaments (string of beads)
Speculum
Cervical/vaginal nodules/lesions (rare)
Investigations
Bedside
Obs
Bloods
FBC (anaemia), haematinics (anaemia)
U+Es, LFTs (baseline, clotting)
Clotting screen (clotting disorder)
Imaging
TV USS:
endometriomas (but often normal)
Laparoscopy:
GOLD standard for diagnosis;
location and extent; biopsy to rule out malignancy
MRI/IV urography/Ba enema:
bladder/bowel disease
Urine
Pregnancy test
Dipstick (UTI)
Swabs
VV/EC swabs (chlamydia, gonorrhoea)
Smear
History
PMH
Clotting disorders, thyroid problems
PSH
Previous abdominal/pelvic surgery
POH
Gravidy/parity, conception, delivery, complications
DH
Contraception, anticoagulants, allergies
PGH
Menstrual cycle, abnormal bleeds, known conditions, contraception, STIs, smear history
PC/HPC
Cyclical pain before/during menses (SOCRATES),
usually after years of non-painful menses
Also menorrhagia, bladder/bowel disturbance
(rectal pain/PR bleeds, painful urination), fertility issues
FH
Endometriosis, cancers, clotting problems
SH
Occupation, smoking/alcohol, diet, support
Stage/Grade (rASRM)
Takes into account location,
size, depth, adhesions
Stage 2 (mild)
Stage 3 (moderate)
Stage 1 (minimal)
Stage 4 (severe)
Management
Medical
Hormonal
COCP
Indication: 2L not needing fertility
MOA: ovarian suppression
SE: headaches, nausea, D+V, stroke, DVT/PE
GnRH analogues
Indication: 3L not needing fertility
MOA: ovarian suppression; may need add-back HRT
SE: menopause (hot flushes, vaginal dryness), loss BMD, headaches, depression
Levonorgestrel IUD
Indication: 1L not needing fertility
E.g. Mirena
MOA: endometrial suppression
SE: irregular bleeding, spontaneous expulsion
Progesterone only
Indication: 2L not needing fertility
E.g. POP, IM depot, implant
MOA: endometrial suppression
Non-hormonal
Mefamamenic acid
Indication: 1L family incomplete
MOA: NSAID, reduces inflammation
and associated pain
Tranaxemic acid
Indication: 1L family inomplete
MOA: increases clotting, reducing
heaviness of bleeds and pain
Analgesia
Indication: pain relief
E.g. NSAIDs, paracetamol
Surgical
Coagulation
Endometrioma excision
Indication: family incomplete
MOA: laparoscopic removal; can improve fertility
Endometrial ablation
Indication: failed medical, family complete
MOA: hysteroscopy and removal of endometrium
Hysterectomy
Indication: failed medical, family complete
MOA: hysteroectomy +/- BOS then add-back HRT
Conservative
Information and advice
Referral to gynae (laparoscopy, treatment)
Complications
Adhesions
Scarring from repeat cycles of
ectopic tissue inflammation
Bowel obstruction
Subfertility
Often need IVF
Endometriomas
Ovarian cysts with blood and
endometrial tissue
Rupture, reduce fertility (distortion of uterus)
Definition
Gynaecological disorder of
chronic pelvic pain caused by
presence of endometrial-like tissue
outside the uterine cavity
Prognosis
Recurrence in upto 50%
of women