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41 Cards in this Set
- Front
- Back
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Definition of endometriosis
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presence of endometrial glands and stroma tissue outside the uterus
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What percentage of reproductive age women does endometriosis affect?
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5-10%
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What factors increase the risk of endometriosis?
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- 1st-degree relative of women with endometriosis (3-10x greater risk)
- reproductive tract anomalies - nulliparity - subfertility - prolonged interval since pregnancy - 20-50% of women undergoing laparoscopy for infertility or pelvic pain have endometriosis |
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What are theories on the etiology of endometriosis?
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1. retrograde menstruation
2. coelomic metaplasia 3. venous/lymphatic spread |
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How can endometriosis-related pain present?
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- dysmenorrhea
- dyspareunia - dysuria - dyschezia - lower back or abdominal discomfort - chronic pelvic pain (non-cyclic abdominal and pelvic pain > 6 months) |
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What are some atypical presentations of endometriosis?
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- cyclic leg pain or sciatica (nerve involvement)
- cyclic rectal bleeding or hematuria (bowel or bladder invasion) - cyclic dyspnea (catamenial pneumothorax) |
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What words can be used to describe endometriosis?
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chronic, progressive, and relapsing condition
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Differential diagnosis for pelvic pain
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- uterine
- primary dysmenorrhea - adenomyosis - ovarian - Mittelschmerz - ovarian cysts (rupture, torsion, etc.) - ovarian remnant syndrome - fallopian tube - hematosalpinx (after TL or ablation) - ectopic pregnancy (acute or chronic) - PID - bowel - IBS - IBD - chronic constipation - bladder - interstitial cystitis - UTI - urinary tract calculi - general - endometriosis - myofascial pain - neuropathic pain - pelvic congestion - adhesions |
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What is the utility of CA-125 in diagnosis of endometriosis?
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- elevated in moderate to severe endometriosis
- sensitivity = 28%, specificity = 90% in women w/ surgically confirmed endometriosis - CA-125 is a component of RMI in undiagnosed pelvic mass |
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What ancillary investigations other than pelvic U/S may be considered for endometriosis?
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- colonoscopy
- barium enema - rectal U/S - cystoscopy - MRI |
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What is the gold standard for diagnosis of endometriosis?
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- direct visualization at laparoscopy
- histologic diagnosis |
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Is laparoscopy required before treatment of suspected endometriosis?
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- no
- overall risk of any complication with laparoscopy = 8.9% (minor or major) |
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What features on history, physical exam, and investigations raise the likelihood of endometriosis?
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- severe dysmenorrhea unresponsive to NSAIDs
- pelvic tenderness and nodularity on palpation of uterosacrals and RV spetum - ovarian cyst with appearance typical of endometrioma on U/S |
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What are some abnormalities in the hormone receptors in endometriosis cells?
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- estrogen receptors are normal
- progesterone receptor isoforms PRA and PRB are markedly diminished in number or absent |
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Medical treatments for endomeriosis
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- combined OCP (continuous > cyclic) - 1st line
- oral progestin (eg. dienogest)/depot progestin - 1st line - Mirena - 2nd line - GnRH agonist w/ addback HT (1mg 17beta-estradiol) - 2nd line - Danazol - less used nowadays - aromatase inhibitors - still experimental - all options should be tried for a minimum of 3 months |
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Disadvantages of DMPA
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- possibility of prolonged delay in resumption of ovulation
- breakthrough bleeding may be difficult to correct - long-term use may decrease BMD |
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Disadvantages of Mirena (LNG-IUS)
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- 5% expulsion rate
- 1.5% risk of pelvic infection - risk of ovarian endometriomas may be increased - BMD effects are unknown |
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Disadvantges of Danazol
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- weight gain
- acne - hirsutism - breast atrophy - virilization (rarely) - lipid concentrations negatively affected - possible increased risk of ovarian cancer |
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List GnRH agonists available in Canada
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- leuprolide acetate (Lupron Depot)
- buserelin (Suprecur/Suprefact injectable) - goserelin (Zoladex) - naferelin (Synarel) - triptorelin (Decapeptyl SR/Gonapeptyl) - triptorelin pamoate (Trelstar) |
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Should incidentally found asymptomatic endometriosis be treated?
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NO
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Indications for surgical management of endometriosis
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- patients with pelvic pain
- who do not respond to or decline medical Rx - acute adnexal event (torsion, ovarian cyst rupture) - invasion of bowel, bladder, ureters, or nerves - patients who have/suspected ovarian endometrioma - the uncertainty of Dx affects mgt - w/ infertility |
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What can conservative surgery for endometriosis involve?
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- direct ablation
- lysis - excision - interruption of nerve pathways - removal of ovarian endometriomas - excision of lesions invading adjacent organs (bowel, bladder, appendix, or ureter) |
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What does definitive surgery for endometriosis involve?
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- bilateral oophorectomy
- excision of all visible endometriotic nodules and lesions - may include removal of uterus and fallopian tubes - should be considered in: - significant symptoms despite conservative Tx - do not desire future pregnancies - undergoing hysterectomy for other conditions |
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Should ablation or excision be performed for superficial endometriosis?
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- no difference in pain outcomes in small RCT
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Definition of deeply infiltrating endometriosis
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- lesions that penetrate 5mm or more
eg. rectovaginal nodule bowel invasion and constriction bladder invasion ureteric invasion or compression nerve involvement (eg. sciatic nerve) |
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What is the recommended surgical approach for ovarian endometriomas?
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- excision of cyst wall provides more benefit than drainage and ablation
- benefits include reductions in: - recurrence of endometriomas - dysmenorrhea - dyspareunia - non-menstrual pelvic pain - requirement for further surgery - cumulative pregnancy rate was higher in cystectomy as well |
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What is the recurrence rate of endometriomas after laparoscopic excision?
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30%
- post-op hormonal suppression does reduce recurrence rate, so should be considered if not seeking pregnancy |
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What nerve ablation procedure may be beneficial in endometriosis-related pain?
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- presacral neurectomy
- NOT uterosacral nerve ablation |
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At what size is removal of endometriomas recommended?
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3 cm in diameter
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the principles of microsurgery
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- magnification
- diligent hemostasis - reduced fulguration - avoidance of tissue drying - limited use of sutures |
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What hormonal therapy is recommended for infertility patients with endometriosis undergoing IVF?
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- GnRH agonist suppression w/ HT addback x 3-6 months before IVF
- associated w/ improved pregnancy rate and symptomatic relief |
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What is the most common cause of secondary dysmenorrhea in adolescents?
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- 10% of dysmenorrhea in adolescents is secondary
- most common cause = endometriosis |
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What timeframe of onset of dysmenorrhea in relation to menarche should raise concerns for outflow obstruction?
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w/in first 6 months after menarche
- endometriosis is present in up to 76% of pts w/ Mullerian anomalies |
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Will endometriosis more likely present as cyclic or acyclic pain in adolescents?
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- >90% acyclic
- 9.4% cyclic pain alone |
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What medical therapies for endometriosis should be avoided in adolescents?
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- GnRH agonist
- DMPA - due to concerns about reduced BMD |
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What are the endometriotic lesions more likely to have in appearance in adolescents?
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- clear vesicles
- red lesions (atypical appearance) |
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What multimodal therapies can be considered in endometriosis apart from medications and surgery?
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- biofeedback
- relaxation - hypnosis - cognitive therapy - acupuncture |
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What are the criteria for diagnosis of malignancy originating from endometriosis?
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1. the presence of both endometriosis and malignancy within the same ovary
2. the carcinoma must arise from endometriosis and not invade it from another source 3. the specimen must contain histological endometriosis including stroma and glands - above 3 by Sampson 4. morphological continuation between benign and malignant epithelium within the endometriosis (by Scott) |
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What are the main histological subtypes of epithelial ovarian cancer that can arise from endometriosis?
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- clear cell
- endometrioid |
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Are women with endometriosis at increased risk for ovarian cancer?
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- yes, ovarian cancer risk (standardized incidence ratio = 1.9) AND overall cancer risk (SIR = 1.2)
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What is the prevalence of malignant transformation from endometriotic lesions?
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- 0.9% using the criteria of Sampson and Scott
- 2.5% if using endometriosis and ovarian cancer in the same ovary - 4.5% if ovarian cancer in women w/ any form of pelvic endometriosis |
