Endometriosis 

Dysmenorrhoea + menorrhagia + abdo/pelvic pain

• Ectopically located endometrial tissue responds to sex hormone stimulation by proliferation, haemorrhage, adhesions and ultimately dense scar tissue changes
• Peak incidence 25-35 years, 10% incidence, average time to diagnosis is 10 years
• Delayed diagnosis can lead to infertility, debilitating pain and reduced QoL
• Varying degrees of symptoms:
  • Non-specific pelvic pain
    • pain has little correlation with the location and extent of disease
    • some patients with endometriosis may be completely asymptomatic 
    • severe dysmenorrhoea that gets progressively worse, impacting on quality of life (lost productivity, days off work/school)
    • recurring or persistent pelvic pain with duration of >6 months
    • worsening dysmenorrhoea while taking hormonal contraceptives
    • ovulation pain
    • deep dyspareunia
    • pain during internal examination
    • back or leg pain.
  • Acute pain with rupture of endometrioma
  • Bowel and bladder symptoms:
    • cyclic bladder or bowel symptoms
    • pain before or after opening bowels
    • pain before, during or after urination
    • bleeding from the bowel blood in the urine
    • irritable bowel syndrome (IBS)type symptoms – constipation, diarrhoea or colic.
  • Bleeding:
    • heavy, irregular, extended or post-coital bleeding with or without clots
    • dark or old blood being passed before or at the end of period 
    • Menorrhagia
    • Premenstrual spotting
  • chronic fatigue, weariness, bloating or pain not during period or ovulation
  • fainting during period or feeling faint
  • nausea
  • depression
  • Infertility
• Examination
  • tender nodules and masses in the pelvis, a tender, retroverted, fixed uterus or implants in the POD or uterosacral ligaments are suggestive of endometriosis
• DDX: PID, ovarian cysts/tumours, uterine myomas
• Possible sites of endometriosis
  • Peritoneum, ovaries and fallopian tubes
  • Uterosacral ligaments and Pouch of Douglas
  • Bladder and bowel
  • Recto-vaginal septum
  • Abdominal surgery scars and, rarely, in other organs outside the pelvic cavity
• Diagnosis: 
  • exclude other causes of lower abdominal pain, eg, sexually transmissible infection (STI), ectopic pregnancy, pelvic inflammatory disease (PID), ovarian torsion, IBS
  • Gold standard: laparoscopy
    • However, false positives can occur with malignancies, endosalpingiosis, carbon deposits from previous ablations and even with normal peritoneum. 
    • A study investigated the accuracy of solely using laparoscopic visualization in diagnosing endometriosis and found that only 67 out of 138 (49%) sites visually positive were also histologically positive – (Am J Obstet Gynecol. 2001;184:1407–1413)
  • Imagin
    • Abdominal/transvaginal ultrasound (TVUS)
      • may be negative
      • may detect endometriomas
      • if ultrasound is performed by gynaecologist trained in advanced ultrasound, it may detect DIE of the bowel, bladder or rectovaginal septum
    • MRI (specialist use).
• Mx: 
  • Patients with persistent pelvic pain should be taken seriously to assist early diagnosis and symptom control.
  • Suggesting the pain is psychosomatic/ psychological can disempower the patient and lead to reduced QoL.
  • Refer to a pain clinic, pain specialist and/or psychologist at the earliest opportunity
• • Pain management:
    • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can provide pain relief by reducing inflammation and prostaglandin production.
    • Paracetamol can be used for mild pain.
    • For severe pain, opioid analgesics like codeine or tramadol can be used, but they should be used with caution due to the risk of addiction and adverse effects.
  • Hormonal therapy – induce amenorrhoea
    • Combined oral contraceptive pills (COCPs) are the first-line therapy for pain and menstrual irregularity in women with endometriosis. They prevent ovulation and reduce endometrial tissue growth.
    • Progestins, such as medroxyprogesterone acetate and norethisterone, can be used alone or in combination with COCPs. They inhibit the growth of endometrial tissue and reduce pain symptoms.
    • Gonadotropin-releasing hormone (GnRH) agonists and antagonists, such as leuprorelin and goserelin, are potent hormonal agents that induce a temporary menopause-like state, thereby reducing the size and activity of endometrial implants.
      • They are reserved for severe or refractory cases of endometriosis due to their high cost and potential adverse effects.
  • Surgical therapy:
    • Laparoscopic excision surgery –  gold standard for definitive diagnosis and treatment of endometriosis
    • Hysterectomy – who have completed childbearing or who have severe, refractory endometriosis.
  • Other therapies:
    • Pelvic floor Physiotherapy
      • pelvic floor muscle strengthening exercises, can help improve pelvic pain and other symptoms.
    • Cognitive-behavioral therapy and other psychological interventions
      • can help patients cope with the psychological impact of endometriosis.