Endometriosis

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  • Endometriosis
    • Ectopic endometrial glands and stroma ectopically growing outside of the uterus, often causing pain and/or infertility. (MCQ)
    • Occurs primarily in women in their 20s and 30s
    • Common in nulliparous woman. (MCQ)
    • Accounts for 20% of chronic pelvic pain.
    • One-third to one-half of women affected with infertility, have endometriosis. (MCQ)
    • Pathophysiology
      • The ectopic endometrial tissue is physiologically functional
      • It responds to hormones and goes through cyclic changes, such as menstrual bleed- ing.
      • The result of this ectopic tissue is “ectopic menses,” which causes bleeding, peritoneal inflammation, pain, fibrosis, and, eventually, adhesions.
    • Sites of endometriosis
      • Common
        • Ovary (bilaterally): 60% (Most common site ) (MCQ)
        • Peritoneum over uterus ,Anterior and posterior cul-de-sacs.
        • Broad ligaments/fallopian tubes/round ligaments ,
        • Uterosacral ligaments. Bowel.
        • Pelvic lymph nodes: 30%.
      • Less Common
        • Rectosigmoid: 10–15%. , Cervix.
        • Vagina. , Bladder.
      • Rare
        • Nasopharynx. , Lungs. CNS , Arms/legs.
        • Abdominal wall. Abdominal surgical scars or episiotomy scar.
    • Theories of etiology
      • Retrograde menstruation:
        • Endometrial tissue fragments are retrogradely transported through the fallopian tubes and implant there or intraabdominally
        • Show predilection for the ovaries and pelvic peritoneum.
      • Mesothelial (peritoneal) metaplasia:
        • Under certain conditions, peritoneal tissue develops into functional endometrial tissue, thus responding to hormones.
      • Vascular/lymphatic transport
        • Endometrial tissue is transported via blood vessels and lymphatics
        • This can explain endometriosis in locations outside of the pelvis (ie, lymph nodes, pleural cavity, kidneys). (MCQ)
      • Altered immunity:
        • There may be deficient or inadequate NK or cell-mediated response.
        • This can explain why some women develop endometriosis, whereas others with similar characteristics do not. (MCQ)
      • Iatrogenic dissemination:
        • Endometrial glands and stroma can be implanted during a procedure (eg, C-section).
        • Endometriosis can be noted in the anterior abdominal wall.
    • Genetic predisposition
      • A woman with a first-degree relative affected with endometriosis has a 7% chance of being similarly affected as compared with 1% in unrelated persons. (MCQ)
      • With a positive family history, a patient may develop endometriosis at an earlier age than the family member.
    • Clinical presentation
      • Pelvic pain (that is especially worse during menses, but can be chronic): (MCQ)
      • Secondary dysmenorrhea (pain begins up to 48 hr prior to menses). (MCQ)
      • Dyspareunia (painful intercourse) as a result of implants on pouch of Douglas; occurs commonly, with deep penetration. (MCQ)
      • Dyschezia (pain with defecation)
        • Implants on rectosigmoid.
      • Infertility.
      • Intermenstrual bleeding.
      • Cyclic bowel or bladder symptoms (hematuria).
      • Up to one-third of women may be asymptomatic.
      • Severity of symptoms (MCQ)
        • does not necessarily correlate with quantity of ectopic endometrial tissue
        • may correlate with the depth of penetration of the ectopic tissue.
      • Long-term complications of endometriosis:
        • Prolonged bleeding causes scarring (adhesions).
        • Adhesions cause infertility, and small bowel obstruction, pelvic pain, and difficult surgeries.
        • Congenital anomalies that promote retrograde menstruation may be a common associated finding in adolescents.
        • Chronic pelvic pain may be a result of endometriosis
      • Signs
        • Fixed retroflexed uterus, with scarring posterior to uterus.
        • Tender uterus or presence of adnexal masses.
        • “Nodular” uterosacral ligaments or thickening and induration of uterosacral ligaments. (MCQ)
        • Ovarian endometriomas
          • Tender, palpable, and freely mobile implanted masses that occur within the ovarian capsule and bleed. (MCQ)
          • This creates a small blood-filled cavity in the ovary, classically known as a “chocolate cyst.” (MCQ)
        • Blue/brown vaginal implants (rare).
    • Diagnosis
      • Laparoscopy or laparotomy:
        • Ectopic tissue must be biopsied for definitive diagnosis.
        • The gold standard for diagnosis is laparoscopy with biopsy proven hemosiderin laden macrophages
      • The colors of endometrial implants vary widely:
        • Red implants—new.
        • Brown implants—older.
        • White implants—oldest (scar tissue).
      • Tissue biopsy (cardinal features): (MCQ)
        • Positive findings contain endometrial glands, stroma, and hemosiderin-laden macrophages.
      • Maximum time on estrogen suppression should be 6 months due to adverse effects.
    • Clinical course
      • 35% percent are asymptomatic.
      • Symptomatic patients may have increasing pain and possible bowel pain and possible bowel complications. (MCQ)
      • Often, there is improvement with pregnancy secondary to temporary cessation of menses.
      • May be associated with infertility.
    • Treatment
      • Medical (temporizing).
        • The primary goal is to induce amenorrhea and cause regression of the endometriotic implants.
        • All of these treatments suppress estrogen:
          • GnRH agonists (MCQ)
            • leuprolide
            • Suppress FSH
            • create a pseudomenopause.
          • Depo-Provera (MCQ)
            • progesterone [+/– estrogen]
            • Creates a pseudopregnancy (amenorrhea).
          • Danazol(MCQ)
            • An androgen derivative that suppresses FSH/ LH
            • cause pseudomenopause.
          • Oral contraceptives (OCPs): (MCQ)
            • Used with mild disease/symptoms.
      • Surgical
        • Conservative
          • Done if reproductivity is to be preserved
          • Laparoscopic lysis and ablation of adhesions and implants.
        • Definitive:
          • Total abdominal hysterectomy and bilateral salpingo-oophorec- tomy (TAH/BSO). (MCQ)
        • GnRH agonist (MCQ)
          • can be used in conjunction with surgical treatment.
          • It is associated with osteoporosis and should be used for only six months.
  • Adenomyosis
    • Ectopic endometrial glands and stroma are found within the myometrium, resulting in a symmetrically enlarged and globular uterus.
    • Occurs in 30% of women.
    • Usually in parous women in their 30s to 50s
    • Rare in nulliparous women.
    • Often coexists with (MCQ)
      • uterine fibroids
      • endometriosis.
  • Signs and symptoms
    • Common
      • Pelvic pain (usually noncyclical).
      • Symmetrical uterine enlargement.
      • Dysmenorrhea (MCQ)
        • progresses with duration of disease.
        • Dysmenorrhea in adenomyosis doesn’t occur as cyclically as it does in endometriosis.
      • Menorrhagia(MCQ)
        • 50% of women are asymptomatic.
        • The diagnosis is usually made incidentally by the pathologist, when examining a surgical specimen.
    • Diagnosis
      • Either ultrasound or MRI can be used to differentiate between adenomyosis and uterine fibroids.
    • Treatment
      • No proven medical therapy for treatment.
      • GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding.
      • Hysterectomy(MCQ)
        • Definitive therapy if childbearing is complete.
        • The diagnosis is usually confirmed after histologic examination of the hysterectomy specimen.
      • Endometrial ablation will not improve adenomyosis symptoms.
  • Adenomyosis: versus Endometriosis:
    • Adenomyosis: (MCQ)
      • Found in older, multiparous women.
      • Tissue is not as responsive to hormonal stimulation.
      • Noncyclical pain.
    • Endometriosis: (MCQ)
      • Found in young, nulliparous women.
      • Tissue is responsive to hormonal stimulation.
      • Cyclical pain
  • Clinical pearls for MD Entrance Exan
    • Endometriosis is the most likely cause of infertility in a menstruating woman over the age of 30, without a history of pelvic inflammatory disease. (MCQ)
    • A 39-year-old woman complains of hemoptysis during the menstrual period. (MCQ)
    • Think: Endometriosis of the nasopharynx or lung.
    • Congenital anomalies that promote retrograde menstruation may be a common associated finding in adolescents.
    • Chronic pelvic pain may be a result of endometriosis associated with adhesions.
    • Classic findings of endometriosis: Dysmenorrhea, dyspareunia, and dyschezia. (MCQ)
    • The classic findings on physical exam are nodularities on the uterosacral ligament and a fixed retroverted uterus. (MCQ)
    • GnRH treatment and pseudo-menopause state. (MCQ)
      • The pulsatile fashion of endogenous GnRH stimulates FSH secretion.
      • GnRH agonists cause down regulation of pituitary receptors and supress FSH secretion. This creates a pseudo-menopause state.
    • Pelvic ultrasounds should be performed to differentiate between adenomyosis and uterine fibroids. (MCQ)
    • Adenomyosis is described as an enlarged, globular, “boggy” uterus on physical exam.


Endometriosis
Transcript and Sources:
Endometriosis is a condition where tissue similar to the lining in your uterus grows in other areas of your body.

Endometriosis surgery

One of the most common health issues experienced among women, and one of the leading causes of infertility, endometriosis occurs when tissue from the endometrial lining implants itself outside the womb. Each month during the menstrual cycle, this tissue sheds just as the lining of the uterus would. Unlike the shedding which occurs from the uterus, however, there is no system in place for this tissue to then exit the body. Scar tissue and adhesions occur, leading to increased levels of pain and often also to infertility.

Endometriosis is a painful, chronic disease that affects 1 in 10 women and girls. It occurs when tissue like that which lines the uterus (called the endometrium) is found outside the uterus (womb) — usually in the abdomen on the ovaries, the fallopian tubes and ligaments that support the uterus. It can also be found in the pelvic cavity. Other sites for endometrial growths include the bladder, bowel, vagina, cervix, vulva and in abdominal surgical scars. Less commonly endometriosis can be found on the arm, leg, lungs, brain and other sites.
Endometriosis
World Endometriosis Society’s first Awareness
World Endometriosis Society launches first ever film to raise awareness of endometriosis

Ending Endometriosis – A DocumentaryIf you or someone you love is suffering from endometriosis, please share this and encourage them to contact Dr. Albee at www.centerforendo.com. The woman behind the documentary is a former patient of Dr. Albee’s who has just celebrated 7-years completely free from endometriosis.