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what is endometriosis?
presence and growth of tissue similar to endometrium outside the uterus
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on what 2 occasions does endometriosis regress? and why?
- pregnancy
- menopause
- as it is oestrogen dependent and in these conditions, less oestrogen around
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what are 2 particular locations for endometriosis?
- uterosacral ligaments
- on/behing ovaries
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where are other occasional sites for endometriosis?
- bladder
- rectum
- lung
- abdominal wound scar
- umbilicus
- vagina
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what is the typical lesion in the ovary called?
- endometrioma - accumulated altered blood which is dark brown
- chocolate cyst
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what is the progression for endometriosis?
- inflammation
- progressive fibrosis
- ADHESIONS
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what happens in the most severe form of endometriosis?
- entire pelvis is FROZEN
- pelvis organs are immobile by adhesions
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what is thought to be the main cause of endometriosis?
retrograde menstruation
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how do more distant foci of endometriosis form?
from mechanical, lymphatic or blood-borne spread
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what is the one main symptom of endometriosis?
- CYCLICAL
- chronic pelvic pain
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what are the main symptoms of endometriosis? (6)
- dysmenorrhoea even before period starts
- deep dyspareunia
- infertility
- dyschezia = pain on passing stools during menses
- cyclical bladder (haematuria) or bowel symptoms - rectal bleeding
- chronic pelvic pain
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why could endometriosis present acutely?
rupture of chocolate cyst in ovary (endometrioma)
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what are the findings O/E of endometriosis
- uterus is retroverted, fixed (due to adhesions)
- nodules on uterosacral ligaments
- tenderness, thickening behind uterus
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how is the diagnosis of endometriosis made?
laparoscopy - visualisation and biopsy
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what can be seen on laparoscopy of endometriosis?
- active lesions: red vesicles
- less active: white scars or brown spots (powder burn)
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what indicates severe disease on laparoscopy?
- extensive adhesions
- endometriomata
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why is TVUS used?
- exclude ovarian endometrioma
- adenomyosis
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if there is evidence of deeply infiltrating endometirosis what Ix is done?
MRI and maybe IVU
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what blood test may be raised in endometriosis but isn't specific?
CA125
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what is differential diagnosis of endometriosis (5)?
- adenomyosis
- PID
- chronic pelvic pain
- other pelvic masses eg ovarian tumour
- IBS
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what happens to endometriosis in over 50% of women?
regresses or does not progress
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what are the 5 options for medical Rx of endometriosis?
- analgesia: NSAIDs/complementary med - as some women don't like to take hormonal therapy
- COCP
- progestogens
- GnRH analogue +- HRT addback
- IUS
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how is the administration of COCP for endometriosis different for usual contraception?
- often used back-to-back or tricycling
- ie no break to reduce frequency of painful withdrawal bleeds
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how would GnRH analogues help in endometriosis?
- induce menopausal state
- lots of GnRH overstimulates pituitary so get downregulation of GnRH receptors
- so the gonadotrophins and ovarian hormone production is therefore inhibited
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what needs to be done if want to use GnRH analogues for >6/12 and why?
- due to reversible demineralisation of bones need to add HRT after 5 months
- prevent bone loss
- and reduce menopausal SE
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what type of Rx would women with endometriosis related pain and infertility usually go for and why?
- surgery - destroy lesions
- as improves conception rates
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if there is severe disease affecting fallopian tubes and pt is suffering from infertility, what is best Rx?
IVF
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what are the 2 main surgical options for Rx of endometriosis?
- laparoscopic laser ablation/diathermy +/- adhesiolysis
- hysterectomy+BSO
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when there is pain during intercourse, what is this called?
deep dyspareunia (not position dependent)
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what happens to endometriosis over time?
gets worse
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what age group and parity are patients with endometriosis likely to be in?
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what is this a typical description of: A 31-year-old nulliparous lady who complains of progressive pain during intercourse which may continue for some time afterwards, occurring at each intercourse and worsening over time.
endometriosis
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what is Fitz-Hugh-Curtis syndrome?
- rare complication of PID
- gonorrhoea or chlamydia cause infection and inflammation in pelvis
- can cause scar tissue to form on Glisson's capsule around the liver
- so get RUQ pain worse on coughing or movement and referred to R shoulder
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what is definition of chronic pelvic pain?
- intermittent or constant pain in the lower abdomen or pelvis
- >6 months
- NOT occurring exclusively with menstruation or sex
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what % of women does CPP affect?
15%
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what 3 Ix could you do for CPP?
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what are 2 causes of ongoing cyclical pelvic pain?
- adenomyosis
- endometriosis
- they are both hormonally driven gynae conditions
- suppression of ovarian activity cures 2/3
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what are features of torsion of ovary?
- acute onset pain
- unilateral - worse on one side
- assoc with N&V
- radiates to upper thighs
- (fever later)
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if suspect mittelschmerz, what do you need to ask?
LMP as its related to ovulation
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what are features of pain relating to endometriosis?
- can start up to 2 weeks before period
- relieved when bleeding starts
- also get deep dyspareunia
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what are features of CPP that point to PID?
- pain across whole of lower abdomen
- vaginal discharge
- fever in the hx
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which 2 bowel conditions can cause pelvic pain and need to be excluded? how distinguish the 2?
- appendicitis: central then right sided, N&V
- diverticulitis: older people, constipation
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what is differential for CHRONIC pelvic pain?
- adenomyosis
- endometriosis
- adhesions
- PID
- gynae cancers
- GI: diverticulitis, IBS
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what is differential for ACUTE pelvic pain?
- PID
- tubo-ovarian abscess: post TOP, IUCD insertion, hysteroscopy
- EPAU: miscarriage, ectoptic
- ovarian cyst: torsion, rupture, bleed
- fibroid necrosis
- mittelschmerz
- abscess: bartholin's abscess
- UTI
- renal stones
- appendicitis
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why do you need to ask about LMP?
- pregnancy, ectopic, miscarriage
- mittelschmerz
- if perimenopausal: atrophic vaginitis leading to superficial dyspareunia
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why do you need to ask about recent gynae procedures - give eg
- insert IUCD
- TOP
- hysteroscopy
- as risk of PID
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if a pt had previous PID, what could now be causing their CPP?
adhesions
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what are risk factors for adhesions causing CPP?
- previous PID
- previous pelvic surgery
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what 2 things need to be asked in sexual hx?
- contraception - if new partner and no barrier method - PID
- difficulty with sex - vaginismus
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what needs to be asked in past obs hx?
- recent childbirth - vaginal lacerations, episiotomy
- superficial dyspareunia
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what are 3 pelvic disease causes of deep dyspareunia?
- endometriosis
- fibroids
- ovarian cyst/tumour
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what are 7 categories of dyspareunia?
- congenital: vaginal atresia/septum
- infection: PID
- post surgery: pelvic floor repair/childbirth related
- vulval: bartholin's cyst, vulval dystrophy, vulval cancer
- pelvic: fibroids, endometriosis, ovarian tumour/cyst
- psychological: vaginismus
- atrophic: postmenopausal
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on bimanual examination, which condition is assoc with cervical excitation?
PID
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if on bimanual tender nodules are felt eg posterior fornix or POD what is it?
endometriosis
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name 5 conditions causing pelvic pain that may present with a pelvic mass?
- endometriosis
- ectopic prengancy
- ovarian cyst/tumour
- fibroid
- tubo-ovarian abscess
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how does the uterus typically feel with adenomyosis?
tender and bulky
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which 5 categories of Ix do we do in pelvic pain?
- bloods: FBC, pregnancy, G&S (in case something ruptures), CRP
- infection screen: MSU, HVS, EC swab, urethral swab
- radiological: USS, AXR
- biopsy for vulval disease
- laparoscopy
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which 5 conditions can laparoscopy diagnose/exclude?
- endometriosis
- adhesions
- ectopic pregnancy
- ovarian cyst
- adhesions
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what are the top 2 most common gynaecological conditions?
- 1. fibroids
- 2. endometriosis
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why do you get cyclical pain in endometriosis?
- because deposits of endometriosis, whatever their location in the body
- respond to ovarian cycle
- bleeding from the deposits causes local irritation and inflammatory responses
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what can rupture of ovarian endometrioma cause?
peritonism due to very irritant 'chocolate' material from the cyst
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