Endometriosis

• Overview:

  • Chronic condition in which endometrial tissue is located at sites other than the uterine cavity (ectopic)
  • Can occur in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs
  • Most women diagnosed aged 25-40
• Aetiology & pathophysiology:

  • Exact pathophysiology is unclear
  • Retrograde menstruation - endometrial cells travel backwards from the uterine cavity through the fallopian tubes and deposit on the pelvic organs. Been suggested that these cells may also travel to distant sites through lymphatic system and vasculature
  • Endometrial tissue is sensitive to oestrogen - will have bleeding from ectopic tissue during menstruation - pain and bloating
  • Repeated inflammation and scarring can lead to adhesions
  • Symptoms will be reduced during pregnancy and menopause
• Risk factors:

  • Early menarche
  • Family history
  • Short menstrual cycles (more often)
  • Long duration of menstrual bleeding
  • Heavy menstrual bleeding
  • Defects in the uterus or fallopian tubes
• Clinical features:

  • Most common symptom is cyclical pelvic pain - when adhesions have formed may be constant
  • Dysmenorrhoea
  • Dyspareunia
  • Dysuria
  • Dyschezia (difficult, painful defecation)
  • Subfertility
  • Those with endometriosis at distant sites may experience focal symptoms of bleeding e.g. blood in urine and stool
• Examination:

  • Bimanual and speculum exam
  • A fixed uterus or cervix
  • Endometrial tissue visible in the vagina
  • General tenderness (an enlarged, tender and boggy uterus is indicative of adenomyosis)
• Investigation:

  • Consider referring women to gynaecology for ultrasound or opinion if endometriosis is suspected
  • Transvaginal ultrasound (or pelvic)
  • Pelvic MRI - do not use as primary investigation but can be used to assess extent of deep endometriosis
  • Gold standard = diagnostic laparoscopy. Consider in women with suspected endometriosis even if ultrasound is normal
  • Definitive diagnosis can be made with a biopsy
  • Can remove endometriosis at time of laparoscopy
• Laparoscopic surgery to excise or ablate the endometrial tissue may improve fertility, hormonal therapy will not improve fertility
• American society of reproductive medicine (ASRM) staging:

  • Stage 1: Small superficial lesions
  • Stage 2: Mild, but deeper lesions than stage 1
  • Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
  • Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
• Analgesia management:

  • NSAIDs and paracetamol first line
• Hormonal management:

  • Suppressing ovulation can cause atrophy of the endometriosis lesions and therefore a reduction in symptoms
  • Combined oral contraceptive pill - can be used back to back with no break (bleed)
  • Progesterone only pill
  • Mirena coil
  • GnRH agonists - induce menopause like state
• Surgical management:

  • Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
  • Relapses will almost certainly occur and surgery may have to be repeated
  • Definitive management is with a hysterectomy and removal of the ovaries, with subsequent replacement of hormones until menopause