Endometriosis
Definition
Ectopic glands and stroma of lining of uterus
(cf. Adenomyosis = growth of glands and stroma into myometrium)
Epidemiology
15-30% of pre-menopausal women
30-45% of infertile women
Aetiology
Risk Factors
Clinical Features
Triad: Dysmenorrhoea, dyspareunia, dyschezia
Symptoms
Menstrual
NOTE: Cyclic pain may gradually advance earlier before menses
Signs
DDX
Ruptured ovarian cyst (usually acute, prior to ovulation/post coital)
Investigations
Imaging:
? severity/ want to give birth
Source
A/Prof Amanda Dennis 2014
Toronto Notes 2012
Ectopic glands and stroma of lining of uterus
(cf. Adenomyosis = growth of glands and stroma into myometrium)
Epidemiology
15-30% of pre-menopausal women
30-45% of infertile women
Aetiology
- Retrograde menstruation (backflow bleeding)
- Metaplasia from coelomic epithelium
- Lymphatic and vascular metastasis
- Iatrogenic dissemination (eg LUSCS scar)
- Immunological defects
- Genetics
Risk Factors
- Age >25
- FHx (1st deg = 7-10x inc)
- Nulliparity
- Obstructive anomalies of genital tract
Clinical Features
Triad: Dysmenorrhoea, dyspareunia, dyschezia
Symptoms
Menstrual
- Chronic ***cyclic*** pelvic pain (any time from mid cycle, relief after menses)
- Secondary dysmenorrhoea (not relieved by OCP/ NSAIDs)
- Dyspareunia
- Abnormal bleeding (premenstrual spotting, menorrhagia)
- Infertility
- Bladder: frequency, dysuria, haematuria
- Bowel: dyschezia, haematochezia. diarrhoea/ constipation
NOTE: Cyclic pain may gradually advance earlier before menses
Signs
- Fixed retroverted uterus with scarring and tenderness post. to uterus - Pouch of Douglas (most common sign)
- Tenderness in Pouch of Douglas
- Nodular uterosacral ligaments on PR exam
- Vesicle of any colour
- Site: Ovaries (most common site: 60%) > Pouch of Douglas > Posterior broad ligaments
DDX
Ruptured ovarian cyst (usually acute, prior to ovulation/post coital)
Investigations
Imaging:
- US (distinguish between endometriosis, adenomyosis, fibroids)
- MRI (not very specific)
- Laparoscopy - Gold standard (chocolate cyst)
- Biopsy (in rare ectopy - eg lung)
- CA125 may be elevated
? severity/ want to give birth
- Medical (to induce amenorrhoea - ↓ oestrogen that stimulates glands)
- OCP
- GnRH agonists (turn off ovary stimulation)
- Androgen
- Progesterone
- Mirena
- Induction of menopause
- Surgical
- Laparoscopic laser/ resection
- Laparotomy
- TAHBSO (total abdo hysterectomy bilat salpingo-oophorectomy)
Source
A/Prof Amanda Dennis 2014
Toronto Notes 2012