what is endometriosis?
presence and growth of tissue similar to endometrium outside the uterus
on what 2 occasions does endometriosis regress? and why?
- as it is oestrogen dependent and in these conditions, less oestrogen around
what are 2 particular locations for endometriosis?
- uterosacral ligaments
- on/behing ovaries
where are other occasional sites for endometriosis?
- abdominal wound scar
what is the typical lesion in the ovary called?
- endometrioma - accumulated altered blood which is dark brown
- chocolate cyst
what is the progression for endometriosis?
- progressive fibrosis
what happens in the most severe form of endometriosis?
- entire pelvis is FROZEN
- pelvis organs are immobile by adhesions
what is thought to be the main cause of endometriosis?
how do more distant foci of endometriosis form?
from mechanical, lymphatic or blood-borne spread
what is the one main symptom of endometriosis?
- chronic pelvic pain
what are the main symptoms of endometriosis? (6)
- dysmenorrhoea even before period starts
- deep dyspareunia
- dyschezia = pain on passing stools during menses
- cyclical bladder (haematuria) or bowel symptoms - rectal bleeding
- chronic pelvic pain
why could endometriosis present acutely?
rupture of chocolate cyst in ovary (endometrioma)
what are the findings O/E of endometriosis
- uterus is retroverted, fixed (due to adhesions)
- nodules on uterosacral ligaments
- tenderness, thickening behind uterus
how is the diagnosis of endometriosis made?
laparoscopy - visualisation and biopsy
what can be seen on laparoscopy of endometriosis?
- active lesions: red vesicles
- less active: white scars or brown spots (powder burn)
what indicates severe disease on laparoscopy?
- extensive adhesions
why is TVUS used?
- exclude ovarian endometrioma
if there is evidence of deeply infiltrating endometirosis what Ix is done?
MRI and maybe IVU
what blood test may be raised in endometriosis but isn't specific?
what is differential diagnosis of endometriosis (5)?
- chronic pelvic pain
- other pelvic masses eg ovarian tumour
what happens to endometriosis in over 50% of women?
regresses or does not progress
what are the 5 options for medical Rx of endometriosis?
- analgesia: NSAIDs/complementary med - as some women don't like to take hormonal therapy
- GnRH analogue +- HRT addback
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
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
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
what type of Rx would women with endometriosis related pain and infertility usually go for and why?
- surgery - destroy lesions
- as improves conception rates
if there is severe disease affecting fallopian tubes and pt is suffering from infertility, what is best Rx?
what are the 2 main surgical options for Rx of endometriosis?
- laparoscopic laser ablation/diathermy +/- adhesiolysis
when there is pain during intercourse, what is this called?
deep dyspareunia (not position dependent)
what happens to endometriosis over time?
what age group and parity are patients with endometriosis likely to be in?
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.
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
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
what % of women does CPP affect?
what 3 Ix could you do for CPP?
what are 2 causes of ongoing cyclical pelvic pain?
- they are both hormonally driven gynae conditions
- suppression of ovarian activity cures 2/3
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)
if suspect mittelschmerz, what do you need to ask?
LMP as its related to ovulation
what are features of pain relating to endometriosis?
- can start up to 2 weeks before period
- relieved when bleeding starts
- also get deep dyspareunia
what are features of CPP that point to PID?
- pain across whole of lower abdomen
- vaginal discharge
- fever in the hx
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
what is differential for CHRONIC pelvic pain?
- gynae cancers
- GI: diverticulitis, IBS
what is differential for ACUTE pelvic pain?
- tubo-ovarian abscess: post TOP, IUCD insertion, hysteroscopy
- EPAU: miscarriage, ectoptic
- ovarian cyst: torsion, rupture, bleed
- fibroid necrosis
- abscess: bartholin's abscess
- renal stones
why do you need to ask about LMP?
- pregnancy, ectopic, miscarriage
- if perimenopausal: atrophic vaginitis leading to superficial dyspareunia
why do you need to ask about recent gynae procedures - give eg
- insert IUCD
- as risk of PID
if a pt had previous PID, what could now be causing their CPP?
what are risk factors for adhesions causing CPP?
- previous PID
- previous pelvic surgery
what 2 things need to be asked in sexual hx?
- contraception - if new partner and no barrier method - PID
- difficulty with sex - vaginismus
what needs to be asked in past obs hx?
- recent childbirth - vaginal lacerations, episiotomy
- superficial dyspareunia
what are 3 pelvic disease causes of deep dyspareunia?
- ovarian cyst/tumour
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
on bimanual examination, which condition is assoc with cervical excitation?
if on bimanual tender nodules are felt eg posterior fornix or POD what is it?
name 5 conditions causing pelvic pain that may present with a pelvic mass?
- ectopic prengancy
- ovarian cyst/tumour
- tubo-ovarian abscess
how does the uterus typically feel with adenomyosis?
tender and bulky
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
which 5 conditions can laparoscopy diagnose/exclude?
- ectopic pregnancy
- ovarian cyst
what are the top 2 most common gynaecological conditions?
- 1. fibroids
- 2. endometriosis
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
what can rupture of ovarian endometrioma cause?
peritonism due to very irritant 'chocolate' material from the cyst