Endometriosis

Question 1

SBA

1st line medical ttt of endometriosis in women w/ chronic pelvic pain

Answer 1

COCs

same effect of GnRH, less side effects

Question 2

What is endometriosis

Answer 2

presence of endometrial-like tissue outside the uterus, which induces a chronic inflammatory reaction.

Question 3

Commonly affected sites of endometriosis

Answer 3

• The pelvic organs and peritoneum (uterosacral ligaments, pouch of Douglas, rectovaginal septum, and ovaries).
• Extra-pelvic deposits such as the lungs, caesarean section scar, and the bowel areoccasionally seen

Question 4

symptoms of endometriosis

Answer 4

1. Secondary dysmenorrhoea (usually before or during menstruation).
2. Deep dyspareunia.
3. Chronic pelvic pain.
4. Infertility.
5. Cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain.
6. Dyschezia (pain on defecation).
7. Painful caesarean section scar.

Question 5

Prevelence of Endometriosis

Answer 5

5–10% among the general female population

Question 6

Percentage of women undrgoing investigations for subfertility who has endometriosis

Answer 6

20-30%

Question 7

percentage of women who undergoing sterilization who has endometriosis

Answer 7

1-5%

Question 8

Percentage of women who has dysmenorrhea or chronic pelvic pain who has endometriosis

Answer 8

40-60%

Question 9

Pathogenesis theories of endometriosis

Answer 9

1. Retrograde menstruation.
2. Peritoneal metaplasia.
3. Lymphatic or blood-borne dissemination.

Question 10

Complications of emdometriosis

Answer 10

• Dysmenorrhoea.
• Chronic pelvic pain.
• Subfertility.
• Can impact on general physical, mental, and social wellbeing.

Question 11

Gold standard investigating endometriosis

Answer 11

Laparoscopy

yet TVS is diagnostic (ground glass appearance)

Question 12

advantage of empirical ttt of endometriosis

Answer 12

• TTT of pain sym without a definitive diagnosis – a therapeutic trial
  of a hormonal drug to reduce menstrual flow is appropriate.

Question 13

what is the empirical ttt of endometriosis

Answer 13

• Analgesia: Prarcetamol, NSAIDs
• MPA (oral,depot)
• Dinogest (Vissane)
• CHC (continous, stop 4-6 month)
• GnRH agonist

Question 14

Investigations of endometriosis

Answer 14

1. Laparoscopy (Gold standard)
2. Serum CA125 (elevated)
3. Histology: if +ve ok, if -ve don’t exclude.
4. TVS (limited value in peritoneal, useful in ovarian)
5. MRI

Question 15

caution in using GnRH agonist in ttt of endometriosis

Answer 15

Add-back therapy (E+P) if GnRH used > 6m, to oppose menopausal like symptoms

Question 16

benefit of hormonal ttt before surgery of endometriosis

Answer 16

no benifit except giving GnRH preoperative if includes bowel, bladder, ureter.

Question 17

surgical options of endometriosis

Answer 17

1. Excision or ablation + adhesiolysis
2. Endometrioma: laparoscopic ovarian cystectomy

Question 18

cutoff level to remove endometrioma

Answer 18

> 3cm

• As reserve can be affected
• AMH should be done bef. and aft. surgery
• AFC isn’t reliable

Question 19

what cancers are in increased risk with endometriosis

Answer 19

1. Ovarian clear cell
2. Endometrioid cancer
3. non hodgkin lymphoma

Question 20

RF for adenomysosis

Answer 20

multiparous 40-50 y premenopausal women

Question 21

adenomyosis is associated commonly with which pathology

Answer 21

leiomyomas up to 70%

Question 22

recurrence after excision of endometrioma

Answer 22

in 2-5y: 30%

81%: same side
11%: contralateral side
8%: both

Question 23

percent of women with deep infiltrating endometriosis who have associated endometrioma

Answer 23

50%

presence of endometrioma indicated more severe disease

Question 24

effect of ttt on fertility in mild endometriosis

Answer 24

Medical: no inc. in natural conception
Surgery: inc. in natural conception
ART: does’t reduce its success

Question 25

effect of ttt on fertility in moderate/severe endometriosis

Answer 25

1. Medical: no inc. in natural conception 2. Surgery: slight inc. but ART is better - associated with reduction in ovarian reserve 3. ART: low eggs no. retrieved, low live birth rate

Question 26

when to do cystectomy of endometrioma before ART

Answer 26

only if the access to the ovaries for oocyte retrival is hard, otherwise it doesn't inc. success rate. | surgery decreases the ovarian reserve, poor response to stimulation

Question 27

adverse obstetric outcome with endometriosis

Answer 27

1. defective implantation * PP * miscarriage * RPL 2. Defective placentation * SGA/FGR * PE * PTL