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Flashcards in endometriosis Deck (41)
1

categories of ddx that mirror endometriosis

pelvic pain
dysmenorrhea
infertility

2

pelvic pain ddx

ectopic pregnancy, PID, intersittial cystitis, adenomyosis, ovarian neoplasms , pelvic adhesions, IBS, colon cancer, diverticular disease

3

dysmenorrhea ddx

adenomyosis, primary dysmenorrhea, uterine leiomyomas

4

▸ Infertility- ddx

hormonal imbalance, inadequate sperm etc.

5

bowel symptoms

IBS, inflammatory bowel disease

6

endometriosis definition

is defined as the presence of endometrial glands and stroma at extrauterine sites

i. Usually located in the pelvis
ii. But can occur nearly anywhere in the body


Common, benign, chronic, estrogen-dependent disorder

7

when is the diagnosis usually made

1. 25-35 years old most common
2. Uncommon on pre/post monarchal girls
3. Rare in post menopausal women NOT taking estrogen

8

who do we see this in

thinner taller white women
higher in higher socio economic classes
asian women

9

increase ris k factors

nuliparity
early menarche or lae menopause
short menstraul cycles
mullerian anomalies

10

lower risk of endometriosis in

multiple births
extended interval of lactation
late menarch

11

theories of endo

Retrograde menstruation/Implantation theory

Hematogenous / lymphatic spread


Coelomic metaplasia


Direct transplantation

Combo?

12

1. Endometrial tissue reflux into the fallopian tubes and implant on neighboring structures

Retrograde menstruation/Implantation theory

Supported by increase incidence in women with genital tract obstructions that prevent expulsion of menses into the vagina
b. However, there are women who have endometriosis but no genital tract obstruction
c. Does not explain how endometriosis gets into other sites

13

Hematogenous / lymphatic spread

1. Spread to outside location by dissemination of endometrial cells through lymphatics and blood vessels

14

iii. Coelomic metaplasia

1. Coelomic (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue

15

how does altered immunity play into endometriosis

Altered Immunity?
a. Deficient cellular immunity and reduction in natural killer cell activity may lead to inability to recognize the presence of endometrial tissue in abnormal locations

16

presenatation of CM of enometriosis

a. Pelvic pain – common complaint
b. Severe dysmenorrhea – will often have to miss school or work b/c periods are so painful
c. Dyspareunia w/ deep penetration
d. Infertility
e. Asymptomatic – may be found on laparascopic surgery for other reasons
f. Constipation/diarrhea
g. Bowel pain
h. Ovarian mass/tumor
i. Dysuria
j. Combination of symptoms
k. Clinical presentation does NOT always correlate to severity of diagnostic findings

17

start to see adhesions in this stage of endometriosis

3

18

what else would you see in stage 3

moderate disease exhibits multiple implants, bother superficial and invasive, Peritubal and periovarian adhesions

19

stage 2

mild enometriosis, superficial implants less than 5 cm in aggreagte, scattered on the peritoneum and ovaries. no significant adhesions

20

stage 1

i. Stage 1: minimal disease—isolated implants and no significant adhesions

21

stage 4

severe disease, multiple superficial and deep implants, including large ovarian endometrioma. filmy and sense adhesions are usually present

22

VII. Endometriomas differ from hemorrhagic cysts

hemorrhagic cyst=fild with bloo

endometrioma-soma and glands

23

Endometriomas would be seen in what stage of endometriosis

4

24

when would you see endometriomas (chocolate cysts)

d. Detected on imaging (US, CT, MRI)

25

how do you dx?

gold standard is surgery but most of the time CM or family hx

▸ Pelvic pain
▸ Severe dysmenorrhea
▸ Dyspareunia
▸ Infertility
▸ Asymptomatic
▸ Constipation/diarrhea
▸ Bowel pain
▸ Ovarian mass/tumor
▸ Dysuria
▸ Combination of symptoms

26

what is the most common presentation

Dysmenorrhea and Pelvic Pain

27

onset is usually around

Onset usually several years after menarche in contrast with primary dysmenorrhea which often begins with menarche

28

pathophysiology of endometriosis

i. Expanding of endometrial tissue in confined spaces
ii. Increase in cytokines, inflammatory factors
iii. Neighboring nerve irritations b/c of the swelling depending on where the implants are

29

Bladder or bowel symptoms

“Typically” presents as urinary frequency during menses, urinary urgency, suprapubic pain at micturition or urinary retention

Pain during the menstrual cycle

“Typically” presents as diarrhea, constipation, dyschezia (pain with bowel movements), and bowel cramping

30

how often do we see infertility with this

Infertility is the presenting symptom in ~ 1/4 of women with endometriosis

31

PE with endometriosis

Tenderness when palpating posterior vaginal fornix

Lateral displacement of the cervix --> typically seen in patients with adhesions or loss of normal anatomy

Localized tenderness or palpable tender nodule in the posterior cul-de-sac or uterosacral ligaments
Tender, enlarged adenxal
mass —> endometrioma

Pain with movement of the uterus

Retroverted or retroflexed uterus

32

Labs and imaging

No clinically useful labs for diagnosis

i. Some studies being done on CA 125 but sometimes seen with ovarian cysts

Pelvic ultrasound is suggested but rarely helpful

Diagnostic laparoscopy is performed to confirm a diagnosis of endometriosis

33

what can ULS help with

ii. BUT can detect some findings that can suggest the diagnosis
1. Endometrioma
2. Rectovaginal or bladder nodule

34

treatment if the pt doesn't want BC

NSAIDS 400-600 q4-6 hours

avoid cox-2 inhibitors if trying to get pregnant --> just Tylenol

35

what kind of OCP

MONOPHASIC PILL
but do want withdraw bleed in 3 months

36

GnRH agonist with add-back

can be used as treatment and (depo-Lupron)

this is NOT birth control need condoms or copper IUD

37

what is the add-back we use with a gnRH agonist for pain treamtent

progresterone

add-back helps decrease hypoestrogenic effects (hot flashes, night sweats etc.) and preserves bone density

38

Aromatase inhibitors

are reserved for women who continue to have refractory symptoms despite GnRH agonist treatment

39

orilissa

will decrease stimulation of the ovaries
GnRH antagonist

40

aromatase inhibtior

catalyse in the synthesis of estrogen

blocks production but can change voice and

41

if the patient had no response to treatment or refractory symptoms

laparoscopy for diagnosis and treatment
benefit should outweigh the risk
council patient about reoccurrence rates

(10% in 3 years)
35% in 5 years