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Endometriosis is characterized by the growth of endometrium-like tissue…
Endometriosis is characterized by the growth of endometrium-like tissue outside the uterus
Definition
most commonly distributed in the pelvis; on the ovaries, uterosacral ligaments, pouch of Douglas, rectum and sigmoid colon, bladder, and distal ureter. Extrapelvic deposits, such as in the bowel, diaphragm, umbilicus, and pleural cavity, are rare.
Endometriosis is hormone mediated and is associated with menstruation. The hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation.
Risk Factors
Early menarche.
Late menopause.
Delayed childbearing.
Nulliparity.
Family history.
Vaginal outflow obstruction.
White ethnicity.
Low body mass index (BMI).
Autoimmune disease (an increased prevalence of autoimmune diseases has been noted in women with surgically confirmed endometriosis) [BMJ, 2019].
Late first sexual encounter.
Smoking.
Complications
Adhesion formation
Bowel obstruction
Fertility problems
Chronic Pain
Endometriomas (ovarian cysts containing blood and endometriosis-like tissue) — if the ovaries are affected, endometriomas may develop. These may rupture and can affect fertility by causing distortion of pelvic anatomy
Reduced quality of life
Differential
Gynaecological conditions, such as PID, Benign ovarian cyst, ovarian cancer, pregnancy, ectopic pregnancy
GI conditions- IBS, coeliac disease, appendicitis, gastroenteritis
Urological conditions, such as recurrent UTIs, interstitial cystitis
Other condition- MSK, cancers, degenerative disc disease
Uterine conditions, such as Adenomyosis or uterine fibroids, Primary dysmenorrhoea, Uterine myoma
Diagnosis
Detailed Hx - sexual Hx, risk of STIs, menstruation cycle. Identify risk factors, exclude differentials, identify complications
Suspect endometriosis in women 17 years or older who display one of the following signs or symptoms- 6 month chronic pelvic pain, dysmenorrhoea affecting QOL, deep pain during or after sexual intercourse, period related painful bowel movements or haematuria/dysuria, infertility with 1 of the above
Pain and symptom diary
Examination- Abdominal and Pelvic examination to identify abdominal masses and pelvic signs, such as reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions
Ix- transvaginal/transabdominal ultrasound, laparoscopy- confirms diagnosis
Management
Pain- 3 month trial of paracetamol and/or NSAIDS if not contraindicated
Assess individual and Support needs- assess for complications
Review after 3-6 months, treatment options
Hormonal Treatment-the combined oral contraceptive pill or a progestogen, such as the progestogen-only pill, implant (Nexplanon®), injectable (Depot-provera® or Sayana Press®), or levonorgestrel intrauterine system (Mirena®).
Referral
referring to a gynaecology service for ultrasound or gynaecology opinion if the woman has: Severe, persistent, or recurrent symptoms of endometriosis, pelvic signs of endometriosis
Consider referring young women (aged 17 years or younger) with suspected or confirmed endometriosis to a paediatric and adolescent gynaecology service, gynaecology service, or specialist endometriosis service (endometriosis centre), depending on local service provision.
Refer to a specialist endometriosis service (endometriosis centre) if the woman has suspected deep endometriosis involving the bowel, bladder, or ureter
Follow up by 2o care if Deep endometriosis involving the bowel, bladder or ureter or
One or more endometrioma that is larger than 3 cm.
Reference-
https://cks.nice.org.uk/endometriosis#!scenario