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Essay 301 - Pelvic pain

Essay 301 - Pelvic pain Posted by PAUL A.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
Posted by Sophia Y.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks].

These symptoms can be caused by gynae pathology as well as urinary, bowel, musculoskeletal & psychological reasons. Sometimes no cause can be identified.
I will ask her if she has these symptoms previously, if so, what was the diagnosis & treatment as recurrence is common. This can also be done by reviewing her old notes.
I will ask her the nature of pelvic pain, whether it is cyclical or not, whether it radiates, precipitating & relieving in relation to menstruation & movements. I will ask her when dysmenorrhoea usually start and finishes as in endometrosis it usually starts before menstruation. I will ask how often she is having deep dyspareunia & whether it has to be stopped. I will ask a detailed menstrual history & ask if she has menorrhagia. I will also ask about irregular period, postcoital bleeding & offensive vaginal discharge as they can be seen in women with pelvic inflammatory disease. I will ask if she has any bowel symptoms like diarrhoea as irritable bowel syndrome can give rise to her symptoms. I will also ask any urinary symptoms such as dysuria, frequency as recurrent urinary infection can give rise to symptoms she is complaining. I will ask if she has children or not as endometriosis & pelvic inflammatory disease (PID) are associated with subfertility. I will ask her what contraception she is using because hormonal treatment may be able to relieve her symptoms as well as providing contraception. In addition an intrauterine contraceptive device (IUCD) might be the cause of dysmenorrhoea. I will ask her how these symptoms have affected her quality of life. I will also ask if she has previous history of PID, in particular chlamydia. I will ask if she has previous pelvic or abdominal surgery, including caesarean sections as adhesions can cause chronic pelvic pain. I will ask any history of depression as women are prone to having symptoms she is complaining. I need to exclude any past medical history and smoking as eg COCP are contra-indicated in hypertension, venous thromboembolism and smokers above 35 years old. I need to ask drug history as there might be interaction with the medications i may consider for treating her.

On examination i will record on body mass index & blood pressure as combined oral contraceptive pill are contra-indicated if they are high. I will examine her abdomen to exclude any pelvic mass. Presence of bowel symptoms with abdominal distension may suggest irritable bowel syndrome. Presence of greenish offensive smelly vaginal discharge on speculum examination may suggest PID. In addition it can identify an IUCD thread. Presence of fixed retroverted uterus with adnexal mass on vaginal examination will highly suggest endometriosis. A tender bulky uterus may suggest adenomyosis.


(b) Critically evaluate the options for investigating her symptoms [4 marks].

Endocervical swabs allow to exclude chlamydia & gonorrhoea infection. High vaginal swab allow us to exclude other causes of PID eg trichomonas vaginalis or gardenella infection. Presence of nitrites & leukocytes on dipstix urine suggests urinary tract infection. Mid-stream urine for microscopy, culture & sensitivty is needed for confirmation. In presence of palpable abdominal or pelvic mass, ultrasound is needed to delineate the nature. Diagnostic laparoscopy is the golden standard of investigation. It can confirm endometriosis, chronic PID and adhesions.

c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].

Treatment will depend on how symptomatic she is, her expectations of treatment outcome, her fertility desire & whether she needs contraception. She may decline any treatment as she may only want a diagnosis to explain her pain. Simple analgesia such as non steroidal anti-inflammatory drugs may be sufficient if she has mild symptoms. If she needs contraception or has no objection despite being sterilised, she can try hormonal treatment in the form combined oral contraception pill (unless contra-indicated) or progestogen (Depo-provera or mirena coil). She should be advised that they can be used as long term. Symtoms will recur once these medications stop. Fertility will not be affected. It might take a year for fertility to resume after a few intra-muscular Depo provera injections. She should be counselled about the side effects of these medications eg weight gain, fluid retention in COCP & Depo provera. Vaginal spotting in progestogen method. Spontaneous expulsion & endometritis can occur, usually on first month of insertion. It can stay for 5 years.

If simple hormonal therapy is not helping, she can try GnRH analogue to suppress ovarian function. She should be told that it can induce menopausal symptoms and so tibolone (synthetic HRT) may reduce the side effects. It is not licensed for for longer than 6 month use because of risk of bone mass density reduction. She should also be told that it does not give contraceptive protection and symptoms recur after medication is stopped. She needs to be counselled properly if she wants to use longer than six months. Bone mass density needs to be checked annually by densitometry and medications to stop if there is sign of osteoporosis.

She can also try danazol but need to be counselled about side effects including hirsutism & deep voice.

Surgical method is indicated if she does not respond to medical treatment. It is also indicated if she declines medical treatment as she is hoping to get pregnant. It should not be performed within 3 months of hormonal treatment. Laparoscopic adhesiolysis, ablation of endometriotic spots and excision of endometrioma to restore normal pelvic anatomy will provide symptoms relief and may improve her fertility. The procedure should be done by competent surgeon who has appropriate training. She should be counselled that laparoscopy is not without risks - bleeding, infection, visceral organ damage, shoulder tip pain, incision hernia and mini-laparotomy. In addition symptoms can recur due to progression of disease.
Posted by Johnson  O.
A/
History would include severity of her symptoms and its effect on quality of life. Menstrual history would include age at menarche, last menstrual period, if her menstrual cycle is regular or irregular. What she is using for contraception. Nature of the pain, if stabbing, dull or sharp. Pain radiation to any part of the body.
Urinary symptoms like dysuria, frequency, urgency or heamaturia to rule out urinary tract pathology. History about her bowel habit, constipation or diarrhoea.
It is important to ask about any previous abdominal or pelvic surgery like laparatomy or laparascopy. Obstetric history should include number of children and mode of delivery. Her desire to have more children. Any psychological problems, her job, family support.
Examination should include her BMI, blood pressure, pulse and temperature. Abdominal scar from previous surgery. Any abdominal/pelvic tenderness, abdominal/pelvic mass. Vagina examination should be done to ellicit any cervical excitation tenderness. Bimanual examination for any retroverted, fixed uterus or palpable adnexial mass. Rectal examination is important.
B/
From her history and examination she may not require any further investigation. Listening and reassurrance may be enough.
Ultrasound scan would be useful where abdominal mass is suspected like endometrioma. However, ultrasound has limited value in endometriosis, most especially peritoneal endometriosis or in adhesion.
Laparascopy is the gold standard. It gives opportunity to treat at the same time. It may also gives psychological reassurance to the woman. It has limitation in that about 30% of laparascopy findings are normal. There are also complications of bowel, urinary tract and major vessel injuries.
Non Gyneacological findings would necessitate referral to appropriate specialty for further investigations.
C/
Treatment would depend on the severity of the symptoms and effect on quality of life, her desire for contraception. Her desire to preserve her uterus and ovaries is also important.
Hormonal contraception would be appropriate where she desire contraception. Combined oral contraception may relieve the symptoms. She needs to know symptoms can return if she stop the medication. Long term hormonal contraception like Implanon or Im Medoxy progestogen are effective contraception and relieve of symptoms. The side effect include weight gain and irregular vaginal bleeding. Norethisterone orally are equally effective but with similar side effect like other progestogen.
Levonogestrel intrauterine contraceptive device last up to 5years and effective. Difficulty with insertion if nulliparous and there is risk of perforation of uterus.
GnRH analogue injection for 3 to 6months. Its side effects include menopausal symptoms, amenorrhea and risk of osteoporosis. If it is require for more than 6months, addback HRT should be given. GnRH analogue would delay her becoming pregnant if this is desired. Danazol uses its limited by its side effect of irreversible virilization.
Non steroidal anti-inflammatory drugs like Naproxen can be used where there are contraindication to hormonal treatment. It may reduce the symptoms but it is not curative.
If pregnancy is desired, laparascopy with ablation of endometriosis spots would improve chances of pregnancy. Laparascopy ovarian cystectomy in endometrioma would improve chances of pregnancy in both spontaneous and IVF pregnancy.
Hysterectomy would be appropriate if family is complete and fertility is not desire. Trial of GnRH analogue needs to be given to observe the beneficial effect before surgery.
The woman needs to be involved in decision making in any form of treatment and her desire is important.
Posted by Mohamed A.
I will ask about the pattern of pain, site, severity, duration, timing, radiation, excacerbating and relieving factors, also pelvic pain outside menstruation. Effects of movements and posture on pain, and its effects on her quality of life. I will ask sensitively about psychological factors, history of sexual assault or intimate partner violence. I will ask about bladder and bowel symptoms (frequency, dysuria, bladder pain may indicate interstitial cystitis, bloating-diarrhoea, pain relieved with defecation may indicate irritable bowel syndrome). I will ask about parity as endometriosis is associated with infertility, mode of deliveries (repeated c.sections a cause of adhesions) also history of infertility. I will ask about previous PID or pelvic, abdominal surgeries. A detailed menstrual history as adenomysois may be associated with menorrhagia. I will ask about contraception history and contraceptive intentions. I will ask about her reproductive intentions and her expectations from treatment.

I will perform abdominal examination for abdomino-pelvic masses, scars of previous surgeries or umbilical nodules (endometriotic). Pelvic exam for pelvic tenderness, fixed RV uterus, tender uterosacral ligament and enlarged ovaries or adnexal masses. Speculum for visible cervical or vaginal endometriotic lesions (rarely). Detection of endometriotic nodules is improved by performing examination during menstruation however patient acceptance is an issue.


b)
Transvaginal ultrasound has limited value in diagnosing peritoneal endometriosis but a useful tool to exclude and diagnose ovarian endometrioms also useful in diagnosing adenomysois.
MRI is useful in identifying deeply infiltrating endometriosis and avoids surgical complication of laparoscopy.
Laparoscopy is the gold standard for diagnosing endometriosis, chronic PID, adhesions and pelvic masses however it has its complications (eg bowel injury) and requires skill.
CA-125 has minimal or no value compared to laparoscopy, however can identify subgroup of women in whom endometriosis is likely for early laparoscopy.
Cervical and vaginal swabs to screen for Chlamydia or Gonorrhea when any suspicion of PID.

c)
Treatment will depend on severity of symptoms, the woman’s reproductive intentions and expectations, suppression of ovulation using combined oral contraception, danazol, gestrinone, Medroxy progesterone acetate or GnRH analogues may be considered. However, woman should be counseled about possible side effects eg hirsutism with danazol and possible loss of up to 6% of bone mineral density over 6 months with GnRHa. COCP and MPA can be used long term but GnRHa for a limited time(add-back therapy with low dose estrogen or Tibolone to prolong therapy), return to fertility usually is not affected with COCP but may delay up to 1 year after MPA.
Duration of therapy should be determined by choice of drug, response to treatment and adverse effects. Another medical option is the LNG IUS with evidence of reduced endometriosis associated pain and symptom control for up to 3 years. Medical treatment is considered for women requiring contraception or whom fertility is not the main concern. Ovarian suppression may do more harm than good in women requiring fertility, however there is evidence that treatment of GnRHa for 3-6 months before IVF in women with endometriosis increase rate of clinical pregnancy.

Surgery may be considered after failed medical treatment or as a first line for women desiring fertility. Laparoscopic ablation of endometriotic lesions, adhesiolysis and laparoscopic cystectomies for ovarian endometioms. usually these measure help to improve symptoms and improve fertility. However risks of laparoscopy should be considered, also requires skill and some women fail to respond to surgery either because of incomplete excision, recurrence or because some of pain was not due to endometriosis from the start.

If tubal function is compromised, IVF is appropriate and laparoscopic cystectomy is recommended for endometriomas > 4 cm in diameter.

Total hysterectomy with bilateral salpingo-oophorectomy with removal of all visible endometriotic tissue may be considered when woman’s family is complete and suffering from debilitating symptoms.

Written information should be provided and consent taken before any surgical procedure. Data about support groups can be found online www.endometrioisis .org
Complementary therapies as high frequency TENS, acupuncture, vitamin B1, homeopathy and refloxology may have a role to improve symptoms.



Posted by Leen K.
LEEN
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].

(a) I would enquire about the nature of her pain, whether it is intermittent or constant, cyclical and whether it is associated with her menstrual cycle (may suggest a gynaecological cause), when the individual symptoms started, how long the pain lasts, and any precipitating factors (certain movement/position may suggest cysts). I would also ask about associated symptms such as menorrhagia (may suggest endometriosis) or bowel symptoms like altered bowel habits (may suggest irritable bowel syndrome) or urinary symptoms like frequency, dysuria (may suggests urinary tract infection). Associated vaginal discharge suggests pelvic infection(s).
I would enquire about her menstrual cycle (last menstrual period, cycle length and regularity) and her contraceptive history (including past and current contraception). Symptoms that improves with combined oral contraceptive use may suggests endometriosis. I would also ask about previous history of pelvic infection or surgeries (adhesions more likely with precious abdominal surgeries). I would also ask her about whether she has noticed any masses in her abdomen.

General examination includes body mass index (BMI), bearing in mind that a high BMI may complicated investigations or treatment. I would perform an abdominal examination looking for masses and cervical excitation (pelvic infection), bulky uterus (ademomyosis or fibroid), adnexal masses or tenderness (cysts or endometriosis) and specifically look for nodules in the pouch of Douglas or posterior fornix of the vagina (endometriosis).

(b) I would organise an ultrasound scan to look for pelvic pathologies such as ovarian cysts or endometrioma; fibroid (pedunculated) or signs suggesting adenomyosis. It will not diagnose endometriosis (except endometrioma) but is hellpful to rule out other diagnoses. An MRI (magnetic resonance imaging) is costly but may be helpful if adenomyosis is suspected.
Diagnostic laparoscopy is the gold standard but is associated with operative risks of visceral organ and vessel injury, but would be indicated if pain persists despite different treatments. It allows diagnosis of endoemtriosis if present, and allows biopsy to be taken for confirmation (if appropriate).

(c) Sometimes explanation of the diagnosis and reassurances to the patient may suffice in terms of management. Otherwise, mefenamic acid or ther non steroidal antiinflammatory drugs many be prescribed, and can be helpful in controlling her symptoms. If she is not wanting to conceive at present, combined oral contraceptive pill may help relieve her symptoms. Depot injection or implants of progestogens thins down the endometrium and can improve pain, as does Mirena coil. These also provides contraception for the woman.
If these measures do not control her symptoms, then Gonadotrophin releasing hormone analogue (GnRHa) will improve symptoms in majority of patients, but prolonged use is not recommended as it thins the bone and can also cause menopausal symptoms. Long term use of GnRHa (> 6 months) is not recommended except for severe cases (of patients still wanting to retain her fertility). Livial addback therapy with GnRHa may alleviate some of the sideeffects, without affecting ttreatment. Symptoms may recur after discontinuation of therapy.

Laser or diathermy of endometriosis laparoscopically is an option but is associated with disease recurrence and some lesions (eg. on bowel or bladder) may not be suitable for removal. Operative risks are higher with bilateral oophorectomy (+/- hysterectomy), and this is not an option for the woman who wants to retain her fertility. It is a major operation with risks of injury to organs, thrombosis and infection. It should only be done in women with extremely symptomatic disease that has not responded to other treatments. These women should be tried on GnRHa with addback HRT to ensure test of cure and tolerance to HRT.

26 mins.
Posted by H H.
A sensitive approach to such patient with symptoms of pain to elicit their effects on her quality of life.A sexual history regarding frequency and if she stopped having sex because of this would detect the severity of the condition.Would ask of her menstrual history,age of menarche, LMP,regularity,duration and relation of pain to her menses ,if felt before her menses and reliefed by its flow or still continued after menses.
Would ask of her contraceptive history and if taking the pills would ask of effect of pills on her symptoms.
Would ask of obstetric history,parity,and wish for more children.Would ask of previous pelvic infection for which she treatment or not.Would ask of urinary symptoms as dysuria, urgency,frequency and hematuria(interstitial cystitis).Would ask of bowel symptoms including bouts of dirrhea and constipstion and change in consistency of stools(Rome criteria), dyskezia and bleeding per rectum eg endometriosis.
Would ask of medical disease like inflammatory bowel disease,of previous surgeries causing adhesions,previous laparoscopy to diagnose her condition and any previous treatments that she took to alleviate her condition. Would ask of psychosexual problems and sexual abuse.
On examination would do BMI, do abdominal examination for abdominal masses (eg fibroid) .speculum examination for vaginal swabs.Local examination for size,mobility of uterus,cervical tenderness,adnexal mass ,nodules in Douglas pouch and to elicit patient symptoms.
B- Would do FBC for white blood cells and do c reactive proteins,if elevated would point to an inflammatory process.However they may be elevated due to any other cause.
Vaginal swabs might be positive for infection, however they may be negative with chronic pelvic infection.
Ca 125 will be elevated in case of endometriosis,however this is non specific as it may be elevated due to other conditions.
Vaginal ultrasound will be of value if pelvic mass is felt. A negative ultrasound might be reassuring to patient , however it might not detect conditions like endometriosis.
MRI is of value in detecting deep infiltrating endometriosis,however it is a costy procedure.
In presence of bowel symptoms, proctoscopy,sigmoidoscopy and colonoscopy are of value but need experienced person. Contrast media like Barium enema can be used but of less diagnostic efficiency than the previous.
Laparoscopy is considered the gold standard of diagnosis but is there is risk of bowel,vascular and bladder injury,infection and anaethetic complications.A negative finding might leave the patient helpless.
C- Treatment options will depend on severity and degree of pain she is experiencing, her fertility wishes and her choice.
There is no evidence that medical treatment will improve fertility in moderate endometriosis and actually most of the medical treatments are contraceptive ,however they are effective in releifing pain.
There is no evidence that surgery (laparoscopic or open) will improve fertility in moderate endometriosis ,however they may releife pain through ablation or surgical excision of endometriotic patches .Laparoscopic uterosacral ablation was found not an effective way of reliefing pain of endometriosis and has less effect than presacral neurectomy.
If main complaint of patient is pain,medical treatment started first.Non steroidal anti inflammatory drugs may not be not effective in endometriosis pain.They are not contraceptive.Combined oral contraceptive pills will releif pain and are contraceptive.They are as effective as gonadotrophic releasing hormone agonists GNRHa in releifing pain.Danazole can be used but limited by its androgenic effects.Gestrinone has less side effects than Danazole. GNRHa use is limited by its development of menopausal symptoms and bone demineralsation. Surgery will be used in cases where medical treatment failed and include ablation with laser or excision.If patient completed family total abdominal hysterectomy and bilateral salpingo oophrectomy is offered, and this should include as well excision of endometriotic tissue.Counseling for need of hormone replacement therapy should proceed this.
If main complaint is infertility, IVF should be offered.Use of Gnrh before IVF might improve results. Despite increased costs it offers good results.
Posted by SANCHU R.
Sanchu
Her severity of symptoms and how much they affect her quality of life should be asked for. Her detailed menstrual history, the onset, duration of pain, any radiation,any aggravating or relieving factors, association with bladder or bowel symptoms should be asked for. Her sexual history should be obtained to find if she is high risk of PID. Her gynaecological history should be obtained to check if she was treated for PID or endometriosis before. Her contraception history should be obtained. Her obstetric history, any fertility problems, whether she has completed her family should be asked for in order to plan management. Surgical history shoul be obtained to consider adhesions as a cause of pain
An abdominal examination should be done to look for tenderness, and palpable masses. A speculum examination may reveal vaginal or cervical endometriotic lesions or excessive vaginal discharge which may indicate PID. Triple swabs should be done to help in diagnosis of PID.
A bimanual examination would be to look for cervical excitation and adnexal tenderness in PID, a tender uterus in adenomyosis, nodules in POD and uterosacral ligament in endometriosis and for adnexal masses.
B)Triple swabs to help in diagnosis of PID should be done. An ultrasonogram of the pelvis should be done. It helps in diagnosing adenomyosis, ovarian endometriomas, hydrosalphinx or tuboovarian mass in chronic PID. But a normal scan does not exclude endometriosis or adenomyosis.
C)Depending on her plans for fertility, the management would differ. If she is planning pregnancy, surgical management would be ideal since medical management precludes pregnancy. Laparoscopy, ablation of endometrial deposits with a histological sample, ovarian cystectomy, adhesiolysis and restoration of normal anatomy and tubal flushing is done
If she does not want to become pregnant in the near future, she can be treated medically with continuous combined oral contraceptives, continuous progestogens, DMPA injections, GnRH analogues with add-back. Danazol is second -line due to androgenic side-effects and should not be used for more than 6 months.
LNG-IUS is an alternative.
If there are endometriomas >4cm on ultrasound , although immediate fertility is not an issue, laparoscopic cystectomy is recommended followed by medical management.
Also, if symptoms do not resolve with medical management, laparoscopy is done.
Posted by Bee N.
Chronic pelvic pain may have a single diagnosis responsible for it but could often be multifactorial. History would inlcude severity, frequency of pain and whether pain is associated with passing urine, deafecation or movement to rule out urinary, bowel or musculoskeletal problems. A pain diary for 2 - 3 months/ menstrual cycle will be of help. History would also include any past or present sexual assault, previous pelvic surgery or laparotomy and previous or present history of pelvic infection.
Examination will include a thourough pelvic exam to elicit pain or nodularity of the uterosacral ligaments and adnexal masses or tenderness which may suggest endometrioma and endometriosis respectively. Bulky uterus will point to possible fibroids or adenomyosis. Cervical excitation tenderness is likely positive for pelvic inflammatory disease. The flexibility of pelvic organs would assesss the severity of adhesions if present. Speculum exam will reveal any discharge.

Options for investigation will depend on likely differentials. If she has bowel related problems, input from gastroenterologists for further investigations would help. Urine can be cultured if necessary. Swabs would include chlamydial, gonoccocal and high vaginal for culture. This may however be negative in the presence of infection and treatment is indicated if high index of suspicion for infection. Pelvic ultrasound scan for adenomyosis has limited value. Magnetic resonance imaging not proven to be better in this regards.Laparoscopy is gold standard and second line of investigation for endometriosis. Findings may be negative in presence of disease. Extent of disease poorly correlates with severity of symptoms in case of endometriosis. Also gives opportunity for indentifying infection, adhesions and treament of endometriosis. laparoscopy also helps woman develop a belief about her pain.

Treatment option for endometriosis are medical or surgical. Medical treatment will inculde use of combined oral contraceptive pills, progestogens such as depot medroxyprogesterone, implanon and levonorgestrel intrauterine system. Danazol and GnRH analogues are also useful. Progestogens, danazol and GnRH analogues should nmot be used for more than 6 months. Progestogens can cause osteoporosis in long term users. Danazol can cause irreversible virilisation and adequate contraception required during its use. Pregnancy must be ruled out befores its use. GnRH analogue can cause post menopausal symptoms and add back therapy required if to ne used for more than 6 months. Failure of treatment with GnRH should trigger consideration of other diagnosisl.Surgical treatment will include laser ablation or helium vapourisation of endometriotic lesions during laparoscopy.This is helpful if infertility is an issue. Hysterectomy and bilateral salpingo ophorectomy is last resort with Hormone replacement therapy. Women\'s chpice should be considered in treatment and consent taken for any surgical procedure. Support groups may help if pain persists.
Posted by Akanksha G.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
a)Elaborate history regarding pelvic pain, its duration severity and effect on quality of life. its relation to menstruation, intercourse, bowel movement, urination. severity of dysmenorrhoea and whether it is progressive, progressive dysmenorrhoea that outlasts menstruation indicates endometriosis, while pain which preceds menstruation can be due to pelvic congestion secondary to adhesions or pelvic inflammatory disease(PID). history of hematuria urgency, urge incontinence indicate interstitial cystitis. history bowel disorders with agrevation or releif with dietary modifications may indicate irritable bowel syndrome. history of pelvic surgeries ( pelvic abscess, endometrioma, ruptured ectopic) may hint towards pelvic adhesions leading pelvic congestion. history of PID inthe past. history of pain while passing stools or bleeding per rectum related to mensus indicates deep infiltrating endometriosis. history of infertility or infertility treatment/ no of conceptions and their outcome (endometriosis and PID associated with infertility) Desire for fertility should also be asked since this also guides treatment. menstrual regularity is not affected in both endometrisis and PID. psychological issues like sexual abuse, history of sexual abuse as a child, domestic violance should be elicited. examination looking for tenderness in suprapubic and iliac fossae pelvic examination would include a speculum and pervaginal examination, speculum examination may reveal lesions of endometriosis on vagina, cervix, posterior fornix, pervaginal examination showing nodularity in pouch of douglas, on uterosacral ligaments, lateral fornicial tenderness, retroverted fixed uterus, indicated endometriosis.
b) pain dairy : maintaining a pain dairy ( for 3 months) of frequency of pain, association with bowel, bladder movements, menstuation, cyclicity may give a clear picture both to the patient and the doctor of the nature of pain. transvaginal ultrasonography is highlt sensitive (90%) in detecting ovarian endometriomas however detection rate for peritooneal endometriosis is poor. diagnostic laparoscopy used to considered a gold standard for investigating cronic pain however now it is considered a second line if conservative and medical measures have failed. laparoscopy helps indetecting peritoneal endometrisis and adhesiions. if interstitial cystitis is suspected, cystoscopy shoud be considered. if deep infiltrating endometrisis is suspected IVP bariam enema MRI may have to be considered to know the extent of the disease. serum Ca 125 ha s poor sensitivity and not routinely used
c) treatment depends of desire for fertility. if patient has completed family and is not keen on furthur issues medical managemnt of mederate endometriosis is effective. medical management involves inducing anovulation with either progesterones (continuous oral or depot injections of medroxy progesterone acetate) oral contraceptive pills ( continuous, sequential, tricyclic), danazol, gestrinone, GnRH anologues. all of them have equal efficacy in controling the symtoms, however with different side effect profiles. danazol causes virilization and hence not acceptable by some women, GnRH anologues causes menopausal symtoms and associated with osteoporosis if used for more than 6 months. however they can be used with add back with estrogen progesterone to prevent osteoporosis for upto 2 yrs. all medical regimens are associated with recurrence after stopping the therapy which may occur in 6-12 month.laparoscopic uterosacral nerve ablation (LUNA) may be considered after carful counselling since not much evidence is available to support its routine use. total abdominal hysterectomy and bilateral salpingoophorectomy with ablation of all the peritoneal disease is curative. treatment of moderate endometriosis with desire for fertility would depend on the presence of ovarian endometrioma.treatment would be in vitro fertyilization and embryo tranfer after resection of the endometriotic cyst.
Posted by robina K.
History and Examination. I will ask about the site and radiation of pain ,relieving factors like defecation which indicates inflammatory bowel diseases and aggravating factors like pain while changing position which indicates adhesions . A history of previous abdominal/ pelvic suggests adhesions ,there may be associated subfertility which should be inquired about .Pain which starts on the first menstrual day and outlasts the whole cycle suggests
endometriosis .Associated symptoms of pain during defecation(dyschezia) and pain during micturation also suggests endometriosis , however dysuria could be due to infection or iterstitial cystitis . A history of vaginal discharge suggests PID. I will sensitively and carefully ask about her sexual history, number of sexual partners and GUM treatment . I will ask ask about her parity, type of deliveries, last delivery and neonatal outcome .A careful history is taken about postnatal depression and domestic abuse/ voilence .Details about treatment at G.P surgery is obtained .
On examination I will asses her emotional and mental state and will look for any sign which suggests abuse/voilence .An abdominal examination is carried out for tenderness and masses .
A sterile speculum examination is carried out to asses the nature of discharge , purulent discharge from endocervix suggests PID /STI , swabs are taken for microbiology .Endometriosis may be visible as black , brown or red spots in vagina, posterior fornix or on cervix . I will perform a bimanual pelvic examination, a fixed retroverted tender uterus indicates endometriosis. There could be nodularity in rectovaginal septum .
(B) Investigations
TVS is offered as it is noninvasive, easily available .can detect ovarian masses which suggests endometriomas .But it has low sensitivity in detecting pelvic and peritoneal endometriosis .
MRI is usefull in dectecting severe and deeply infiltrated lesions but its role in detecting moderate and superficial endometriosis is not very helpful.It is expensivs, needs equipment and expertise .
Laparoscopy is cosidered as gold standared for the diagnosis of endometriosis and adhesions, and can be used as therapeutic tool for adhesiolysis and ablation. However it can only detect superficial endometriosis.There are risks of laparoscopy like visceral and vascular injury, post op shoulder tip pain infection .Expertise and equipment is needed .
(C) Treatment options are medical which could be non hormonal or hormonal and surgical treatment .Choice of treatment depends on her most distressing and cocerned symptoms like pain or subfertility and her wishes for a particular treatment . If her concern is only pain which has not been relieved with analgesics I will offer her combine oral cotraceptive pills continously for 3-4 months. COCP supresses ovulation and inflammatory activity in the endometriotic spots thus effective in relieving pain . A therapeutic trial may be offered before diagnostic tests .COCP is associated with nausea ,vomiting, fluid retention. bloatedness and depression.
Gestrinone is weakly androgenic anti estrogen and anti progestogen.,Has less side effects than danazol and it effectively reduces endometriosis associated pain.
GNRH analogues given as depots or nasal sprays supresses ovulation by supressing pitutary gonadotrophins .It causes osteoporosis if used for more than 6 months.There is a 6% loss of bone mass density by 6 months and may not recover completely.To prevent bone mass density loss addback therapy with estrogen and progestogens may be cosidered .
Danazol is another option ,it is effective in the treatment of endometriosis but has severe side effect profile like acne, hirsuitism, and masculinisation of female fetous ,so effective contraception is needed .Dnazol increases bone mass density .
Laparoscopic adhesiolysis and ablation of endometriotic spots is also effective in relieving pain and should be offered if medical treatment fails .
If womens concern is subfertility ,hormonal treatment is cotraindicated.Laparoscopic adhesiolysis and tubal flushing may improve pregnancy rate and should be offered .Before dignostic laparoscopy husbands semen analysis should be carried out .



Posted by Asa A.
asa
a) The triad of pelvic pain, dysmenorrhea and dysparunea points to endometriosis ,however every effort should be done to explore other possibilities . Sympathetic approach to the patient is important to allow her to tell all her story and express her views regarding her complaint .She will be asked about nature of the pain, aggravating and relieving factors , whether it is cyclic or related to menstruation and areas of radiation . Specific sites and relation to movements will be asked for .Associated symptoms will be asked for through direct questions like urinary complaints in the form of frequency ,nocturia , urgency and dysuria . Bowel symptoms like bloating , change in the form of stools and dyschasia should not be missed. Detailed menstrual history regarding cycle regularity ,dysmenorrhea pre or during or postmenstrual . Contraceptive history is important and current use of IUCD as it may be displaced . Whether she has used OCPs and their effect on the pain . Sexual history and number of partners or recent change of partner may give a clue to pelvic inflammatory disease . Obstetric history regarding previous birth trauma or difficult delivery may indicate pelvic floor injury or spasm. Infertility problems and future fertility wishes are important in planning therapy .Previous drugs received and any previous abdominal surgeries will be enquired about. I will examine her abdominally for specific sites of pain ,masses or scars . Pelvic examination for pelvic tenderness ,tender uterosacral ligaments , fixed tender uterus , any sign of infection in the cervix, and any pelvic masses(endometriomas).Examination during menstruation may be more informative if the woman consents to it .

b ) Investigation will include swabs for cultures& sensitivity if signs of pelvic infection are detected . The same applies for urine analysis if she has urinary complaints . Pelvic ultrasound is a good test for diagnosing endometriomas or otherpelvic masses but it has no role in diagnosing peritoneal disease . MRI could be of benefit in diagnosing deeply infiltrating disease and verifying the nature of endometrioma but it is expensive and not recommended for routine use . CA125 is not specific or sensitive for endomrtriosis but it can be high in severe cases . Barium enema and IVU should be done in case of suspected severe disease.
The gold standerd for diagnosing endometriosis is laparoscopy . Endometriotc spots or lesions could be seen and their location and extent identified and the presence of adhesions . Ideally biopsy will be taken for definitive diagnosis and exclusion of rare instances of malignancy(0.7%) . However there remains the risk of bowel and urinary injuries are in the range of 1-3 % and mortality rate for diagnostic laparoscopy is 1/100000 .

c ) Options available for treating moderate endometriosis are either medical or surgical and depends on the patient choice and fertility wishes . Treatment of pain using NSAIs is not of proven efficacy but some women may opt for it trying to avoid hormonal treatment . The same applies for alternatives like homeopathy and herbal medicine .
Hormonal treatment in the form of combined contraceptive pills or danazol or Gnrh agonists for 3-6 months to suppress ovulation is of benefit for reducing endometriotic pain . OCPs can be used for long periods but side effects of GNRH analogues especially the bone loss of6% bone mass in 6 months prevents their use more than 6 months unless addback low dose HRT is given simultaneously .
Levonorgestrel IUS could be of benefit in reducing dysmenorrhea and pelvic pain .
Surgical treatment for moderate endometriosis ideally should be done with diagnosis of endometriosis during laparoscopy if informed consent is taken . Removal of lesions using diathermy or laser or surgical excision together with adhesolysis is of definite effect in alleviating endometrial pain . The effect is not the same for minimal endometriosis . Surgery should be done by experienced staff in a multidisciplinary system as other organs like bowel may be affected or injured. Total abdominal hysterectomy and bilateral salpingooopharectomy is the most extensive surgery option and may be offered if all other options failed .
For patients with moderate endometriosis who are infertile , no clear evidence exists for the benefit of either hormonal or surgical treatment and they should be referred to an in fertility center for management.
Treatment of endometriosis could be frustrating and it takes time to accept the disease facts so sympathy and support groups are of great help to the patients.
Posted by shipra K.

A) The woman on history should be asked for type of pain spasmodic or continous,radiation of pain to back(could be musculoskeletal) lumbar region (ureteric colic,pyelonephritis),aggravating factors ,if aggravated on movement musculoskeletal in origin,relieving factors.any discharge per vaginum (PID),associated urinary complaint.like increased frequency ,burning during micturition(UTI), pain &hematuria(interstitial cystitis).Any associated bowel complaint like blood or mucus in stools,pain during defecation,increased frequency associated with particular food intake(inflammatory bowel syndrome).History of previous pelvic surgery,history of past or ongoing sexual abuse.history of psychiatric illness especially depression.Patients menstrual history if menorrhagia(PID, fibroid uterus).Obstetrical history infertility would again point towards endometriosis.Sexual history number of sexual partners(multiple partners-PID).
On examination a general examination to note BMI. Thorough per abdominal examination to look for any abdominal masses ,per speculum examination to see for cervicitis ,vaginitis,mass arising from cervix vagina,discharge.Per vaginum examination to note size of uterus ,uterine tenderness,adenexal mass,thickened tender uterosacral.

B)FBC as a part of routine investigation and would tell if any infection present,urine routine microscopic would show any urinary tract infection.Urine culture sensitivity if pus cells on routine. Cervical & vaginal swabs.Transvaginal sonography would show any mass in pelvis,though not very sensitive for adenomyosis.MRI better in detecting adenomyosis,any other cause. Patient with chronic pelvic pain diagnostic laparoscopy is the gold standard for investigation but complications of bowel perforation damge to major vessels need to be explained..

C)The treatment would depend on patients desire for fertility,severity of problem . Initial treatment with analgesics like naproxen can be tried.If fertitilty not desired then patient can be given progesterone or combined oral contraception .Danazol,gestrinone have androgenic side effects and cannot be given for a prolonged period. Patient can be given LNG IUS would be help but may cause irregular spotting and chances of expulsion there.

GnRH analogues can be given again not for prolonged period as cause osteoporosis(6% boneloss in 6 months)so should not be given for prolonged period not more than 6 months if given alone. With add back therapy (low dose oestrogen progesterone combination or tibolone ) can be for 2 years.
.If desirous of children or not improving on medical treatment then laparoscopic surgical ablation of of endometriotic implants, adhesiolysis,removal of endometriomas give good results and restores pelvic anatomy.patient to be referred to an infertility specialist
Lastly if unresponsive and fertility not required.then total abdominal hysterectomy with bilateral salpingoopherectomy.if disease in rectovaginal septum resection should be done.

Posted by G. K.
The above mentioned symptoms are sugggestive of endometriosis. However,Other conditions which may cause similar symptoms should be excluded by a detailed history and examination.
A thorough history should be taken with regards to the severity of symptoms and their impact on her quality of life.Specific questions relative to her pain such as cyclical/non cyclical ,nature, such as sharp, dull or stabbing should be inquired about. Any aggravating or relieving factors should be inquired about. The relation of pain to any bowel symptoms such as painful defecation, constipation or diarrhoea should be asked. Similarly inquire about bladder symptoms such as dysuria, frequency ,hesitancy.Inquire about any associated vaginal discharge which is discoloured ,foul ,smelling or itchy/sore.
Inquire about any medical problems such as irritable bowel syndrome or interstial cystititis or musculoskeletal pain or fibromyalgia , since the presence of any of those can contribute to her symptoms.
also inquire about previous surgeries such as caesarian section or laaprotomy for any other reason such as ovarian cysts since adhesions formation after surgeries can also complicate the picture due to adhesion formation. Similarly inquire about chronic PID or past history of chlamydia/ gonorrhoea infection since it can also cause the above mentioned symptoms due to adhesion formation.
Inquire about parity, her desire to preserve fertility.
Sensitively inquire about any psychological issues which be causing or compounding the problem.
Examination should include height, weight, blood pressure. Abdominal examination to look for any surgical scars, palpation of any abdominal masses.
Vaginal inspection for obvious endometriotic nodules, and an internal examination for mobility, size of uterus, cervical tenderness should be done. Palpate for any adnexal masses and palpable nodules suggestive od endometriosis in the POD. Take endocervical swabs for chlamydia , gonorhoea and a high vaginal swab to rule out other infections such as bacterial vaginosis .

B)
Transvaginal ultrasound is good at detecting adenomyosis and endometriomas but can not detect peritoneal endometriosis.
MRI or transvaginal ultrasound can also detect adenomyosis.
Laparoscopy is the gold standard for detecting endometriosis and chronic PID. Although deeply infiltrating endometriosis can be mistakenly diagnosed as mild disease.
Histology of the lesion at the time of laparoscopy can diagnose endomtriosis or but negative histology does not exclude it.
C)
Treatment options depend upon the severity of symptoms, their impact on the quality of life, the desire to retain fertility and her ovaries.The wishes of the patient is important in determining the type of treatment .
Medical management of her symptoms can be done by hormonal methods such as combined oral contraceptive pill (provivded there are no contraindications), progesterone danazol or GNRh analogues to suppress the ovarian function for a period of 3 to six months with add back Tibolone or estrogen and progesterone .
Levonorgestrel intrauterins system can be tried to reduce the pain of endometriosis alongwith any associated menorrhagia.
Surgical option include laparoscoy and adhesiolysis, ablation of endometriotic deposits, and cystectomy for endometriomas .
Complimentary therapies such as high frequncy TENs, reflexology or homeopathy can be tried if the patient is reluctant to go for medical or surgical treatment options.
Councelling for patients with psychological issues may be all that is needed or could be in combination with above mentioned therapeutic options.


Posted by A A.
(PART A ) I will ask about severity of symptoms and its effects on her quality of life. I will ask about nature of pain (colicky,dull ache,burning), site,constant or intermittent and its association with menstruation, micturition, defecation or any movement /posture. Any aggravating and relieving factor. I will ask about regularity of menstrual cycle, amount of bleeding (menorrhagia can be due to fibroid),cycle length,IMB or PCB. Regarding contraceptive history, use of IUCD(for PID), current use and future contraceptive wishes. Regarding gynaecological history I will ask about history of vaginal discharge, sexually transmitted diseases and its treatment(for PID0.History of subfertility, chronic fatigue, dysmenorrhoea, pelvic pain,dyspareunia,dyschezia and cyclical hematuria/rectal bleeding are more suggestive of endometriosis.In obstetric history, parity of the woman, last child birth, any antenatal /postnatal complications,miscarriages, utrine instrumentation and TOP (more likely lead to PID). History of weight loss, alternating constipation/diarrhoea, bloating, rectal bleeding is more in favour of inflammatory bowel disease / irritable bowel syndrome(follow Rome criteria).Urinary symptoms like frequency, urgency, bladder pain is more in favour of interstitial cystitis(IC).I will make sensitive enquiry about psychological and sexual abuse and any stressful events.Symptoms like postcoital bleeding,wt loss,rectal bleeding and irregular periods are more in favour of neoplasm(ovarian). In examination I will check BMI.In abdominal examination I will check for abdominal distension,tenderness, rebound tenderness, any abdominal mass, palpable bladder. On speculum examination I will look for any discharge, any visible cervical / vaginal endometriosis spots (bluish spots) and take endocervical swabs. In vaginal examination(VE) I will check for uterine size, position and mobility (fixed retroverted ut in endometrioses). I will look for adenexal masses and tenderness. Deeply infiltrating endometriosis is best detected if examination done during menstruation depending upon women acceptance of VE during menstruation.

(Part B) USG is non invasive, good at detecting pelvic pathology especially if missed during clinical examination like ovarian mass, any other pelvic mass, fibroids and calculating risk of malignancy index.It is operator dependent and good quality equipment.It cannot diagnose peritoneal endometrioses.Serum CA125 is increased in endometriosis,ovarian malignancy and in many other conditions,therefore less sensitive and specific as a screening/diagnostic tool alone.FBC and CRP are increased in inflammatory bowel disease but further investigations like Colonoscopy/contrast studies should be undertaken by gastroenterologist. Laproscopy is gold standard investigation, it can diagnose pelvic endometriosis,pelvic masses, uterine adhesions and is also therapeutic (adhesiolysis and ablation of endometrotic spots) but it carries anesthetic/ operative risk like bowel, bladder, vessel damage (0.6 /1000 to 1.8 /1000).Laproscopy could also be normal so woman should be informed about it preoperatively.Deeply infiltrating nodules can be mistaken as minimal disease and IBS and adenomyosis cannot be detected.MRI is non-invasive,avoid surgery and can detect pelvic endometriosis /pelvic masses but there is insufficient evidence that it is a useful test to diagnose or exclude endometriosis compared to laparoscopy. Urine dipsticks and MSU culture for (interstitial cystitis / UTI). Cystoscopy will be required for diagnosis of IC.

(Part C) Treatment options depend upon severity of the disease, previous treatment,her acceptance for treatment and woman’s concern whether she want pain management or infertility treatment.I will ask about the previous treatment history of women,whether she has taken NSAID/hormonal agents like COCP, progesterone and her compliance to treatment for at least 6months.If she has already taken this,then it is no more effective further.If fertility is not an issue and she accepts medical therapy for pain management , GNRHagonist with addback therapy (estrogen and progesterone) for 2years is an option that protects against BMD loss at lumber spine during and for 6months after treatment has stopped.The postmenopausal symptoms were less severe with add back therapy and compliance required.Other option is LNG-IUS,it appears to reduce endometriosis associated pain with symptoms control maintained over three years.Compliance is not a problem but associated with irregular bleeding for first 6months and breast tenderness.In Surgical option laproscopic ablation of endometriotic lesions reduce the pain compared with diagnostic laparoscopy alone(63%improvement VS 23% in RCT) at 6months.Similarly surgical excision was associated with80% improvement in pain VS32% in placebo at 6months and this improvement in pain remains at 12month assessment except dyschezia.Presacral neurectomy may have some role if conservative laparoscopy has failed but it is more complex procedure and has greater morbidity.Hystrectomy and BSO is an option as a last resort ,it reduces pain by removing entire lesion.But women will be informed that ideal regimen for HRT after bilateral oophorectomy is unclear and will be given after assessment on indavidualized basis.If fertility management is required ,suppression of ovarian function with hormonal agents has no place.The role of excisional/ablation surgery in improving pregnancy rates in moderate disease is uncertain.IVF is appropriate treatment especially if tubal function is compromised.There is also concern about cost and risk of multiple pregnancy/OHSS with IVF.Treatment with GNRH agonist for 3-6months before IVF increases pregnancy rate.Laproscopic ovarian cystectomy is recommended for endometriomas>4cm in diameter because it reduces infection risk,improves access to follicle/ovarian response and prevent endometriosis progression.There is also risk of reduced ovarian function/loss,so women should be counselled about it.I will provide written information of above discussion and address of support groups likeNational Endometriosis Society .
Posted by Dr Saritha M.
a)
A history of pelvic pain ,dysmenorrhea and dyspareunia though suggestive of endometriosis, detailed history is enquired to rule out other causes. pelvic pain in relation to menstruation like dysmenorrhoea, menorrhagia is enquired. Bladder symptoms like dysuria, frequency is enquired to rule out urinary tract infection. Bowel symptoms like change in the frequency, consistency of stools, difficult defecation to rule out irritable bowel syndrome is enquired.Symptoms of Pelvic inflammatory disease like lower abdomen tenderness, any vaginal discharge, previous history of pelvic inflammatory disease is enquired. History of back ache suggestive of musculoskeletal system is enquired. Past history of any pelvic surgeries for the same complaints or any other surgeries are enquired. Obstretic history in details regarding sub fertility or any treatments for conception is enquired.history of any contraceptive method like Intra uterine device for pelvic inflammatory disease is enquired. Histroy of fever vomiting or localised abdominal tenderness like appendicitis is enquired.
On examintaion; Last menstrual period details, Per Abdomen examination for the site of tenderness, any mass papable in the pevis or lower abdomen is looked for. Also for guarding and rebound tenderness is looked for. Bimanual examination for uterine size, mobiity, tenderness, fornicial tenderness or any mass, nodularity in the pouch of douglas is felt.
B)
Mid stream urine sample for microscopy and culture if required. Trans vaginal ultra sound for fibroid, adnexal mass and ovarian endometrioma. But absent of cystic structures do not exclude endo metriosis. Laparoscopy is only reliable diagnostic test for for endometriosis. look for superificial endometriosis, adhesions, look for pouch of douglas. But depth of infiltration is related to the symptoms rather than the extent of involvement. CA-125 is raised but it is neither sensitive or specific. MRI has role in diagnosing deep pelvic endometriosis. but for small deposits its role is uncertain.
C)
Treatment depends on the symptom predominance:
Medical treatment : suppression of ovarian cycles for atleast 6 months is effective in controlling the pain. but symptom recurrence after stopping the treatment to be explained to woman. (50% recurrence within 1-2 yr of stopping treatment) Continued oral contraceptives helps by decreasing the pain, and has got good compliance , more useful in non smokers. Medroxy progesterone acetate is also beneficial but side effects like acne,wt gain,mood swings has to explained. GnRH analogues with add back therapy to improve pain and to protect form loss of bone mineral density for six months. Danazol is also effective has got anti estrogenic and anti progestogenic effect, immuno suppressive properties. after counseling the side effects like acne, oliy skin, wt gain. advise about the need of contraception is done.
LNG IUS is also effective for dysmenorrhoea and heavy menstrual bleeding, has additonal contraceptive benefits.
Surgical treatment; Adequate pre op counselling and consent has to be taken. Indicated if subfertiity is the concern as first line of treatment, pain improvement ,ovarian endometrioma.
Ideal is laparoscopic surgery to excise the visible lesions or ablation using laser, or electro diathermy. release of adhesions, cystecomy is carried out. Simultaneously tubal fiushing to improve the pregnancy rates. there is no role of pre or post op medicaltreatment for endometriosis. the role of presacral neurectomy and uterine nerve ablation is inconclusive.
conservative treatment is advocated only in asymptomatic woman.
Adequate counselling is required , patient self help groups provides invaluable support and advice.
Posted by Manoj M.

M
(a) A history of severity of symptoms with quality of life affected, cyclical (perimenstrual pain) may suggest endometriosis.
Bowel pain on movement or relief of symptoms on emptying bowel may suggest bowel related pain/ deep infiltrating endometrisis.
Bladder pain e.g. pain relieved on emptying bladder may suggest bladder cause for pain.
Her previous pregnancies and outcomes should be established as subfertility may suggest tubal disease.
Her detailed menstrual history may suggest need for treatment options for heavy bleeding along with pain control.
Her sexual history including number of partners and past history of any sexually transmitted infections e.g. chlamydia may suggest cause for pain.
Details of treatment she had from GP for her current symptoms may suggest need for alternate options.
General physical examination including pulse, BP, BMI as she may need a surgical procedure.
Abdominal examination to localise pain and exclude abdominal masses.
Speculum examination may reveal local vaginal or cervical endometrisis however this is rare and provides opportunity for endocervical and vaginal swabs if not done prior by GP.
Bimanual examination may reveal fixed, retroverted tender uterus/ tender uterosacral / rectovaginal nodules may suggest severity of endometriosis, palpable ovaian mass may suggest endometrioma.

(b)Laparoscopy is the gold standard for diagnosis pelvic endometriosis, it helps to visualise and confirm diagnosis of peritoneal endometriosis, however needs to mobilise or palpate suspected deeper nodules and may not visualise deeper endometriosis. A positive histology will confirms endometriosis but a negative histology will not exclude the diagnosis. Laparoscopy has its own inherent risk of laparoscopic injuries like bowel, bladder and need general anaesthesia for the procedure.
Transvaginal ultrasound or pelvic ultrasound has limited value in diagnosis endometriosis compared to laparoscopy, howvever is useful to exclude diagnosis of ovarian endometrioma when clincally suspected.
CA125 may be elevated with endometriosis but has no diagnostic value compared with laparoscopy.
If clinically suspected with significant endometriosis like ureteric / bladder involvement or rectovaginal nodules then MRI, IVP and barium enema studies as appropriate for mapping extent of disease may help before considing surgical treatment.

(c)This depends on patients wishes including her fertility choices.
Medical treatment options include ovarian function suppression with combined oral contraceptive pills as a therapeutic trial for atlest 6 months may suppress endometrisis but likely to recurr on stopping treatment, sideeffects like bloatedness, breast tenderness, mood changes should be explained
Alternatively medoxyprogesterone acetate can be used in those not suitable for oestrogen again with side effect profile explained.
Mirena coil is effective in controlling pain related to endometriosis and also helps in reducing heavy menstrual bleeding.
GnRH analogue with add back HRT is a useful treatment for upto 6 months.
Danazol and Gestrinone are useful in treatment but their side effect profile like androgen effects limits its use.
Laparoscopic surgical ablation/ removal of visible endometriosis is a treatment option howerver, may need complex surgery with MDT including surgeons, urologist for deeper infiltrating disease and available only in certain centres.
Ovarian endometrioma of more than 4 cms should be removed to confirm diagnosis and exclude underlying malignancy, but risk of oopherectomy.
If tubal factor is suspected with endometriosis, tubal flusing may improve fertility rates.
Bilateral oopherectomy with HRT is an alternative option if no fertility wishes in future and depending on severity of disease.
If tubal disease and fertility affected may need IVF as treatment option.
Other treatment with complimentary therapies have no evidence as treatment option.
She should be provided with information leaflets and details of support groups.
Posted by Shalini  M.
shalini
a)It is emperative to begin bysympathetically listening to the complaints of this ladyand then taking a detailed history of pain-whether it is cyclical or continous;any aggravating or relieving factors and any relation to movement or posture.Any previou history of PID is important as she could be suffering from chronic PID.Also a detailed menstrual history-frequency,duration of bleeding as also history of IUCD usage in the past and present contraceptive in use as use of IUCD in the past could also be responsible for chronic PID.Obstetric history of this lady is important-whether she has previous normal births or cesarean sections as adhesions also can cause pevic pain.Any history of sexual abuse or psychological problems must be enquired into.Any urinary complaints should be asked for like bladder pain,urgency and frequency as interstitisl cystitis could also be causative of pelvic pain.Also bowel complaints like constipation,diarrhoea,distensionand weight loss should be enquired into to rule out any irritable bowel syndrome or inflammatory bowel disease as the cause.On examination,abdominal distension,tenderness,rebound tenderness,presence of mass should be looked for.on pelvic examination,cervical motion tenderness ,uterine size,mobility,tenderness,adnexal mass,tendernessas also tendrness or palpating nodules along the uterosacral ligament should be noted.Also a rectal examination is done to palpate tender nodules along uterosacral ligament.
b)Transvaginal ultrasound has a sensitivity of 65%-68% and a specificity of 68%-95% for adnexal masses and ovarian endometriosis can be picked up.Also MRI can diagnose peritoneal endometriosis as also uterine pathology with a sensitivity of 70-85% and specificity of 85-88%.Gold standard of diagnosis is diagnostic laproscopy as small peritoneal endometriosis can be picked up.However adenomyosis and conditions like inflammatory bowel disease can be missed and also there is no pathology found in atleast 15% of laproscopies.They have a risk of death 1/10,000 and 2.4/1000 of risk of visceral and vessel injury with two-thirds of them requiring laprotomies that must be explained to the lady.Use of conscious pain mapping during laproscopy is becomin popular to find out the exact cause of pain.If gynaecological and non-gynaecoogical cause of pain cannot be distinguished on the basis of history and examination then GnRh analogues can be used to suppress ovarian activity and if relief is experienced it is gynaecological.
c)Treatment options can be decided upon her most important complaint.If she wants pain relief NSAIDs can be used as also co-co-cydramolol that has been found to be effective.Uterine nerve ablations have not been found to be very effective in pain relief.If she wants contraception then combined contraceptive pills ca be precribed as they suppress ovarian activity and are effective in pain due to endometriosis.Also danazol can be used but due to androgenic side-effects this is not preferred.Gnrh analogues can be used if pain is not relieved with any prescription but risk of side-effects of estrogen deficiency should be explained as also irreversible bone-loss.If she wants conception then IVF should be offered as there is no role of IUI and ovarian stimulation.She should be adequately counselled about risks of IVf like multiple pregnancy,ectopic pregnancy and ovarian hyperstimulation syndrome that acn occur.Presence of hydrosalpinx has an adverse effect on outcome of IVF and should be removed before it.Also ovarian endometrioma more than 4 cm should be removed to relieve symptoms and for histological confirmation of diagnosis.
Posted by PAUL A.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks].

These symptoms can be caused by gynae pathology as well as urinary, bowel, musculoskeletal & psychological reasons. Sometimes no cause can be identified.
I will ask her if she has these symptoms previously, if so, what was the diagnosis & treatment as recurrence is common question says 9 months history . This can also be done by reviewing her old notes.
I will ask her the nature of pelvic pain, whether it is cyclical or not, whether it radiates, precipitating & relieving in relation to menstruation & movements how will this help you? . I will ask her when dysmenorrhoea usually start and finishes as in endometrosis it usually starts before menstruation does this help you distinguish endometriosis from other causes? . I will ask how often she is having deep dyspareunia & whether it has to be stopped ? meaning . I will ask a detailed menstrual history & ask if she has menorrhagia. I will also ask about irregular period, postcoital bleeding & offensive vaginal discharge as they can be seen in women with pelvic inflammatory disease do you get these in chronic PID?? . I will ask if she has any bowel symptoms like diarrhoea as irritable bowel syndrome can give rise to her symptoms how would you diagnose IBS? Diarrhoea is not enough . I will also ask any urinary symptoms such as dysuria, frequency as recurrent urinary infection can give rise to symptoms she is complaining (1) . I will ask if she has children or not as endometriosis & pelvic inflammatory disease (PID) are associated with subfertility. I will ask her what contraception she is using because hormonal treatment may be able to relieve her symptoms as well as providing contraception (1) current / previous contraception and fertility wishes . In addition an intrauterine contraceptive device (IUCD) might be the cause of dysmenorrhoea. I will ask her how these symptoms have affected her quality of life. I will also ask if she has previous history of PID (1) , in particular chlamydia. I will ask if she has previous pelvic or abdominal surgery, including caesarean sections as adhesions can cause chronic pelvic pain. I will ask any history of depression as women are prone to having symptoms she is complaining. I need to exclude any past medical history and smoking as eg COCP are contra-indicated in hypertension, venous thromboembolism and smokers above 35 years old. I need to ask drug history as there might be interaction with the medications i may consider for treating her. ? psycho-sexual Hx – you have spent too much time and space on Hx. You will not get marks for general things like drug history… unless there are specific drugs that are relevant

On examination i will record on body mass index & blood pressure as combined oral contraceptive pill are contra-indicated if they are high. I will examine her abdomen to exclude any pelvic mass. Presence of bowel symptoms with abdominal distension may suggest irritable bowel syndrome. Presence of greenish offensive smelly vaginal discharge on speculum examination may suggest PID ? acute or chronic PID? There is a 9 months Hx . In addition it can identify an IUCD thread. Presence of fixed retroverted uterus with adnexal mass on vaginal examination will highly suggest endometriosis (1) . A tender bulky uterus may suggest adenomyosis.


(b) Critically evaluate the options for investigating her symptoms [4 marks].

Endocervical swabs allow to exclude chlamydia & gonorrhoea infection. High vaginal swab allow us to exclude other causes of PID eg trichomonas vaginalis or gardenella infection do this cause PID – that is upper genital tract infection? What do lower genital tract swabs tell you about the cause of upper genital tract infection? . Presence of nitrites & leukocytes on dipstix urine suggests urinary tract infection. Mid-stream urine for microscopy, culture & sensitivty is needed for confirmation ? 9 months Hx?? . In presence of palpable abdominal or pelvic mass, ultrasound is needed to delineate the nature. Diagnostic laparoscopy is the golden standard of investigation. It can confirm endometriosis, chronic PID and adhesions CRITICALLY EVALUATE. Evaluate means ‘attach value’ – how useful are these investigations? CRITICALLY – find faults – what are the limitations / side-effects… of these investigations? .

c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].

Treatment will depend on how symptomatic she is, her expectations of treatment outcome, her fertility desire did not write in (a) & whether she needs contraception. She may decline any treatment as she may only want a diagnosis to explain her pain not necessary . Simple analgesia such as non steroidal anti-inflammatory drugs (1) may be sufficient if she has mild symptoms. If she needs contraception or has no objection despite being sterilised where does sterilisation appear in the question? , she can try hormonal treatment in the form combined oral contraception pill (1) (unless contra-indicated) or progestogen (Depo-provera is this recognised treatment for endometriosis?? or mirena coil). She should be advised that they can be used as long term. Symtoms will recur once these medications stop. Fertility will not be affected. It might take a year for fertility to resume after a few intra-muscular Depo provera injections. She should be counselled about the side effects of these medications eg weight gain, fluid retention in COCP & Depo provera. Vaginal spotting in progestogen method. Spontaneous expulsion & endometritis can occur, usually on first month of insertion. It can stay for 5 years.

YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE If simple hormonal therapy is not helping, she can try GnRH analogue to suppress ovarian function. She should be told that it can induce menopausal symptoms and so tibolone (synthetic HRT) may reduce the side effects. It is not licensed for for longer than 6 month use because of risk of bone mass density reduction. She should also be told that it does not give contraceptive protection and symptoms recur after medication is stopped. She needs to be counselled properly if she wants to use longer than six months. Bone mass density needs to be checked annually by densitometry and medications to stop if there is sign of osteoporosis.

She can also try danazol but need to be counselled about side effects including hirsutism & deep voice.

Surgical method is indicated if she does not respond to medical treatment. It is also indicated if she declines medical treatment as she is hoping to get pregnant. It should not be performed within 3 months of hormonal treatment. Laparoscopic adhesiolysis, ablation of endometriotic spots and excision of endometrioma to restore normal pelvic anatomy will provide symptoms relief and may improve her fertility. The procedure should be done by competent surgeon who has appropriate training. She should be counselled that laparoscopy is not without risks - bleeding, infection, visceral organ damage, shoulder tip pain, incision hernia and mini-laparotomy. In addition symptoms can recur due to progression of disease.


Your answer is far too long and is not focused. You need to look at all the possible things you can ask the woman and decide which are the most relevant. This should be based on the most likely diagnoses
Posted by PAUL A.
A/
History would include severity of her symptoms and its effect on quality of life. Menstrual history would include age at menarche, last menstrual period, if her menstrual cycle is regular or irregular how will this help you manage dysmen / dyspareunia? . What she is using for contraception (1) how will this help you?. Nature of the pain, if stabbing, dull or sharp how will this help you reach a diagnosis / treat her? . Pain radiation to any part of the body.
Urinary symptoms like dysuria, frequency, urgency or heamaturia to rule out urinary tract pathology. History about her bowel habit, constipation or diarrhoea you need more detailed GI history as IBS / IBD are possible diagnoses .
It is important to ask about any previous abdominal or pelvic surgery like laparatomy or laparascopy. Obstetric history should include number of children and mode of delivery how does it help? 3 previous CS compared to nullip – what is the difference? . Her desire to have more children (1) . Any psychological problems you need to be more specific and detailed , her job ? relevance- if you took the time to write how any of these would help, you will not include most of them , family support. ? nature of treatment by GP
Examination should include her BMI, blood pressure, pulse and temperature ? value in a woman with 9 months Hx of pain . Abdominal scar from previous surgery. Any abdominal/pelvic tenderness, abdominal/pelvic mass. Vagina examination should be done to ellicit any cervical excitation tenderness. Bimanual examination for any retroverted, fixed uterus or palpable adnexial mass (1) . Rectal examination is important why? .
B/
From her history and examination she may not require any further investigation which diagnoses can you make in this situation based purely on Hx and examination? . Listening and reassurrance may be enough.
Ultrasound scan would be useful where abdominal mass is suspected like endometrioma. However, ultrasound has limited value in endometriosis, most especially peritoneal endometriosis or in adhesion (1) .
Laparascopy is the gold standard. It gives opportunity to treat at the same time. It may also gives psychological reassurance to the woman. It has limitation in that about 30% of laparascopy findings are normal. There are also complications of bowel, urinary tract and major vessel injuries (1) .
Non Gyneacological findings would necessitate referral to appropriate specialty for further investigations. inflammatory markers (IBD), CA-125 (endometriosis), MRI scan
C/
Treatment would depend on the severity of the symptoms and effect on quality of life, her desire for contraception. Her desire to preserve her uterus and ovaries is also important.
Hormonal contraception would be appropriate where she desire contraception. Combined oral contraception (1) ? simple analgesia like NSAIDS may relieve the symptoms. She needs to know symptoms can return if she stop the medication. Long term hormonal contraception like Implanon or Im Medoxy progestogen are effective contraception and relieve of symptoms ? recognised treatment for endometriosis?? . The side effect include weight gain and irregular vaginal bleeding. Norethisterone orally are equally effective but with similar side effect like other progestogen (1) .
Levonogestrel intrauterine contraceptive device last up to 5years and effective (1) . Difficulty with insertion if nulliparous and there is risk of perforation of uterus.
GnRH analogue injection for 3 to 6months. Its side effects include menopausal symptoms, amenorrhea and risk of osteoporosis. If it is require for more than 6months, addback HRT should be given (1) . GnRH analogue would delay her becoming pregnant if this is desired. Danazol uses its limited by its side effect of irreversible virilization.
Non steroidal anti-inflammatory drugs like Naproxen can be used where there are contraindication to hormonal treatment (1) why not as first line? . It may reduce the symptoms but it is not curative are any of the other treatments curative? .
If pregnancy is desired, laparascopy with ablation of endometriosis spots would improve chances of pregnancy her complaint is pain – will this treatment relieve pain? . Laparascopy ovarian cystectomy in endometrioma would improve chances of pregnancy in both spontaneous and IVF pregnancy.
Hysterectomy key issue – would you conserve ovaries in these circumstances?? would be appropriate if family is complete and fertility is not desire. Trial of GnRH analogue needs to be given to observe the beneficial effect before surgery.
The woman needs to be involved in decision making in any form of treatment and her desire is important.
Posted by SUNDAY A.
Sunday\'s answer

a)I would ask about the pattern of the symptoms- if its cyclical with associated symptoms like menorrhagia, backpain and bowel symptom such as constipation, change in bowel habit . I would also exclude any urinary symptoms such as frequency, urgency, dysuria. A family history of endometriosis would be explored and information about how the symptoms is affecting her quality of life. I would also ask about previous gynaecological operation with indication and outcome.On examination i would check for any tenderness or palpable mass on the abdomen, previous scars from past surgeries and a pelvic examination to demonstate any adnexal tenderness or palpable mass. A rectal examination may be indicated for deep infiltarting lesion affecting the rectum.

b) A triple swab may be indicated to rule out any infective cause though this is unlikely. A Pelvic scan may be indicated particularly if a mass is suspected in the abdomen or pelvis. A normal scan may not rule out the presence of endometriosis and small lesion may not be picked up on scan. Diagnostic laparoscopy is the gold standard but in about 20% of patients a negative finding at laproscopy may be the case.

c) Options include a conservative approach where by symptoms are treated with painkillers depending on the severity of the symptom and patients preference. Other option include the use of Hormonal preparation such as the combined pill which can be back to back. Progesterone in form of Mirena ius has shown some benefit in some patients. Danazol has some benefits but the major draw back is the side effect. The GnRH analogue such as zoladex can be tried but not for more than 6 months with add-back HRt such as tibolone. Surgical option may be required if the above option has failed and this will require laparoscopy and excision of the endometritic spots, TAH+ BSO may be required depeding on the severity of her symptoms and future desire for fertility.

Posted by PAUL A.
I will ask about the pattern of pain, site, severity, duration, timing, radiation, excacerbating and relieving factors, also pelvic pain outside menstruation. Effects of movements and posture on pain how useful are these in helping you reach a diagnosis / treat her? Is there any of these that will make you think endometriosis or chronic PID / IBS…? , and its effects on her quality of life. I will ask sensitively about psychological factors, history of sexual assault or intimate partner violence (1) . I will ask about bladder and bowel symptoms (frequency, dysuria, bladder pain may indicate interstitial cystitis, bloating-diarrhoea, pain relieved with defecation may indicate irritable bowel syndrome) (1) . I will ask about parity as endometriosis is associated with infertility, mode of deliveries ( repeated c.sections a cause of adhesions have you ever made a diagnosis of chronic pelvic pain due to adhesions from CS?? ) also history of infertility. I will ask about previous PID (1) or pelvic, abdominal surgeries. A detailed menstrual history as adenomysois may be associated with menorrhagia. I will ask about contraception history and contraceptive intentions. I will ask about her reproductive intentions (1) WHAT ABOUT PREVIOUS TREATMENT? and her expectations from treatment.

I will perform abdominal examination for abdomino-pelvic masses, scars of previous surgeries or umbilical nodules (endometriotic). Pelvic exam for pelvic tenderness, fixed RV uterus, tender uterosacral ligament and enlarged ovaries or adnexal masses (1) . Speculum for visible cervical or vaginal endometriotic lesions (rarely). Detection of endometriotic nodules is improved by performing examination during menstruation however patient acceptance is an issue. WHAT ABOUT FEATURES OF INFLAMMATORY BOWEL DISEASE?


b)
Transvaginal ultrasound has limited value in diagnosing peritoneal endometriosis but a useful tool to exclude and diagnose ovarian endometrioms also useful in diagnosing adenomysois (1) .
MRI is useful in identifying deeply infiltrating endometriosis and avoids surgical complication of laparoscopy (1) .
Laparoscopy is the gold standard for diagnosing endometriosis, chronic PID, adhesions and pelvic masses however it has its complications (eg bowel injury) and requires skill (1) .
CA-125 has minimal or no value compared to laparoscopy, however can identify subgroup of women in whom endometriosis is likely for early laparoscopy what about inflammatory markers? .
Cervical and vaginal swabs to screen for Chlamydia or Gonorrhea when any suspicion of PID.

c)
Treatment will depend on severity of symptoms, the woman’s reproductive intentions and expectations, suppression of ovulation using combined oral contraception, danazol, gestrinone, Medroxy progesterone acetate or GnRH analogues may be considered this is a list of drugs with different safety profiles. Why not address them one at a time? . However, woman should be counseled about possible side effects eg hirsutism with danazol and possible loss of up to 6% of bone mineral density over 6 months with GnRHa (1) ? add back therapy . COCP and MPA can be used long term but GnRHa for a limited time(add-back therapy with low dose estrogen or Tibolone to prolong therapy), return to fertility usually is not affected with COCP but may delay up to 1 year after MPA do you mean depo-MPA? Is this a recognised treatment for endometriosis? .
Duration of therapy should be determined by choice of drug, response to treatment and adverse effects. Another medical option is the LNG IUS with evidence of reduced endometriosis associated pain and symptom control for up to 3 years (1) . Medical treatment is considered for women requiring contraception or whom fertility is not the main concern ? simple analgesia like NSAIDS . Ovarian suppression may do more harm than good in women requiring fertility, however there is evidence that treatment of GnRHa for 3-6 months before IVF in women with endometriosis increase rate of clinical pregnancy.

Surgery may be considered after failed medical treatment or as a first line for women desiring fertility what about at the time of diagnosis if consented? . Laparoscopic ablation of endometriotic lesions, adhesiolysis and laparoscopic cystectomies for ovarian endometioms. usually these measure help to improve symptoms (1) and improve fertility. However risks of laparoscopy should be considered, also requires skill and some women fail to respond to surgery either because of incomplete excision, recurrence or because some of pain was not due to endometriosis from the start.

If tubal function is compromised, IVF is appropriate there is no mention of fertility in the question, just pain and laparoscopic cystectomy is recommended for endometriomas > 4 cm in diameter.

Total hysterectomy with bilateral salpingo-oophorectomy with removal of all visible endometriotic tissue (1) may be considered when woman’s family is complete and suffering from debilitating symptoms.

Written information should be provided and consent taken before any surgical procedure. Data about support groups can be found online www.endometrioisis .org
Complementary therapies as high frequency TENS, acupuncture, vitamin B1, homeopathy and refloxology may have a role to improve symptoms ? evidence

You would have gained more marks if you addressed individual medical treatment options separately
.
Posted by PAUL A.
LEEN
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].

(a) I would enquire about the nature of her pain, whether it is intermittent or constant, cyclical and whether it is associated with her menstrual cycle stated in the question - dysmenorrhoea (may suggest a gynaecological cause), when the individual symptoms started 9 months Hx , how long the pain lasts, and any precipitating factors (certain movement/position may suggest cysts). I would also ask about associated symptms such as menorrhagia (may suggest endometriosis) or bowel symptoms like altered bowel habits (may suggest irritable bowel syndrome) this is insufficient to suggest or diagnose IBS – there are strict criteria or urinary symptoms like frequency, dysuria (may suggests urinary tract infection) will you expect this to present with a 9 months Hx of the symptoms in question? . Associated vaginal discharge suggests pelvic infection(s).
I would enquire about her menstrual cycle (last menstrual period, cycle length and regularity) and her contraceptive history (including past and current contraception) (1) . Symptoms that improves with combined oral contraceptive use may suggests endometriosis. I would also ask about previous history of pelvic infection (1) or surgeries (adhesions more likely with precious abdominal surgeries). I would also ask her about whether she has noticed any masses in her abdomen.

General examination includes body mass index (BMI), bearing in mind that a high BMI may complicated investigations or treatment. I would perform an abdominal examination looking for masses and cervical excitation (pelvic infection), bulky uterus (ademomyosis or fibroid), adnexal masses or tenderness (cysts or endometriosis) and specifically look for nodules in the pouch of Douglas or posterior fornix of the vagina (endometriosis) (1) .

(b) I would organise not answering the question – you were not asked to describe / discuss what you would do an ultrasound scan to look for pelvic pathologies such as ovarian cysts or endometrioma; fibroid (pedunculated) or signs suggesting adenomyosis. It will not diagnose endometriosis (except endometrioma) but is hellpful to rule out other diagnoses (1) . An MRI (magnetic resonance imaging) is costly ? more expensive than laparoscopy? but may be helpful if adenomyosis is suspected.
Diagnostic laparoscopy (1) is the gold standard but is associated with operative risks of visceral organ and vessel injury, but would be indicated if pain persists despite different treatments. It allows diagnosis of endoemtriosis if present, and allows biopsy to be taken for confirmation (if appropriate). ? blood tests??

(c) Sometimes explanation of the diagnosis and reassurances to the patient may suffice in terms of management. Otherwise, mefenamic acid or ther non steroidal antiinflammatory drugs (1) many be prescribed, and can be helpful in controlling her symptoms. If she is not wanting to conceive at present, combined oral contraceptive pill may help relieve her symptoms (1) . Depot injection or implants of progestogens thins down the endometrium and can improve pain what if the woman develops irregular (frequent) bleeding? , as does Mirena coil (1) . These also provides contraception for the woman.
If these measures do not control her symptoms, then Gonadotrophin releasing hormone analogue (GnRHa) (1) will improve symptoms in majority of patients, but prolonged use is not recommended as it thins the bone and can also cause menopausal symptoms. Long term use of GnRHa (> 6 months) is not recommended except for severe cases (of patients still wanting to retain her fertility). Livial do not use trade names addback therapy with GnRHa may alleviate some of the sideeffects, without affecting ttreatment. Symptoms may recur after discontinuation of therapy applies to all medical treatments .

Laser or diathermy of endometriosis laparoscopically (1) is an option but is associated with disease recurrence and some lesions (eg. on bowel or bladder) may not be suitable for removal. Operative risks are higher with bilateral oophorectomy (+/- hysterectomy) (1) if you are removing ovaries, why leave uterus behind? You will have to go back and remove it if her pain persists , and this is not an option for the woman who wants to retain her fertility. It is a major operation with risks of injury to organs, thrombosis and infection. It should only be done in women with extremely symptomatic disease that has not responded to other treatments. These women should be tried on GnRHa with addback HRT to ensure test of cure and tolerance to HRT (1) .

26 mins.
Posted by PAUL A.
A sensitive approach to such patient with symptoms of pain to elicit their effects on her quality of life.A sexual history regarding frequency and if she stopped having sex because of this would detect the severity of the condition.Would ask of her menstrual history, age of menarche You were not asked to take a gynae Hx. You were specifically asked about those bits that will help you make a diagnosis or treat the woman. So how will age at menarche help you for instance? If this is not obvious then there are no marks , LMP,regularity,duration and relation of pain to her menses ,if felt before her menses and reliefed by its flow or still continued after menses. the question says pelvic pain, dysmen and deep dyspareunia – means she gets pain when not menstruatiog.
Would ask of her contraceptive history (1) and if taking the pills would ask of effect of pills on her symptoms.
Would ask of obstetric history,parity,and wish for more children (1) .Would ask of previous pelvic infection (1) for which she treatment or not.Would ask of urinary symptoms as dysuria, urgency,frequency and hematuria(interstitial cystitis).Would ask of bowel symptoms including bouts of dirrhea and constipstion and change in consistency of stools(Rome criteria) (1) , dyskezia and bleeding per rectum eg endometriosis.
Would ask of medical disease like inflammatory bowel disease,of previous surgeries causing adhesions,previous laparoscopy to diagnose her condition and any previous treatments that she took to alleviate her condition (1) . Would ask of psychosexual problems and sexual abuse (1) .
On examination would do BMI, do abdominal examination for abdominal masses (eg fibroid) .speculum examination for vaginal swabs.Local examination for size,mobility of uterus,cervical tenderness,adnexal mass ,nodules in Douglas pouch and to elicit patient symptoms.
B- Would do FBC for white blood cells and do c reactive proteins,if elevated would point to an inflammatory process.However they may be elevated due to any other cause (1) .
Vaginal swabs might be positive for infection, however they may be negative with chronic pelvic infection.
Ca 125 will be elevated in case of endometriosis,however this is non specific as it may be elevated due to other conditions.
Vaginal ultrasound will be of value if pelvic mass is felt. A negative ultrasound might be reassuring to patient , however it might not detect conditions like endometriosis (1) .
MRI is of value in detecting deep infiltrating endometriosis,however it is a costy procedure how do costs compare to laparoscopy?.
In presence of bowel symptoms, proctoscopy,sigmoidoscopy and colonoscopy are of value but need experienced person. Contrast media like Barium enema can be used but of less diagnostic efficiency than the previous.
Laparoscopy is considered the gold standard (1) of diagnosis but is there is risk of bowel,vascular and bladder injury,infection and anaethetic complications.A negative finding might leave the patient helpless.
C- Treatment options will depend on severity and degree of pain she is experiencing, her fertility wishes and her choice.
There is no evidence that medical treatment will improve fertility in moderate endometriosis and actually most of the medical treatments are contraceptive ,however they are effective in releifing pain.
There is no evidence that surgery (laparoscopic or open) will improve fertility there is no mention of fertility in the question – your focus should be treating her pain while taking fertility wishes into account NOT treating fertility in the context of her pzin in moderate endometriosis ,however they may releife pain through ablation or surgical excision of endometriotic patches (1) .Laparoscopic uterosacral ablation was found not an effective way of reliefing pain of endometriosis and has less effect than presacral neurectomy.
If main complaint of patient is pain WHY IF? IS THERE ANY OTHER COMPLAINT IN THE QUESTION APART FROM PAIN??? THE EXAMINER WILL NOT ASK YOU ABOUT AND THEN REQUIRE AN ANSWER ABOUT FERTILITY ,medical treatment started first.Non steroidal anti inflammatory drugs may not be not effective in endometriosis pain ??? .They are not contraceptive.Combined oral contraceptive pills will releif pain (1) and are contraceptive.They are as effective as gonadotrophic releasing hormone agonists GNRHa in releifing pain.Danazole can be used but limited by its androgenic effects.Gestrinone has less side effects than Danazole. GNRHa use is limited by its development of menopausal symptoms and bone demineralisation (1) ? add back . Surgery will be used in cases where medical treatment failed and include ablation with laser or excision (1) .If patient completed family total abdominal hysterectomy and bilateral salpingo oophrectomy is offered (1) , and this should include as well excision of endometriotic tissue.Counseling for need of hormone replacement therapy should proceed this (1) .
If main complaint is infertility, IVF should be offered.Use of Gnrh before IVF might improve results. Despite increased costs it offers good results.

You scored very well in the end but should have done so with time to spare if you focused on the question asked
Posted by C P.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
C
The diagnosis is chronic pelvic pain which can cause physical, social and psychological effect on this patient. Her symptoms could be due to Endometriosis, Chronic pelvic inflammation or adhesion. Rarely it can be due to non gynaecological condition. Keeping this in mind I will focus my history to this patient.
In the history I will asses how her symptoms affects her personal, social, psychological and professional life.
Any previous pelvic infection or treatment of STI would suggest she may suffer from chronic pelvic inflammatory disease. If she had undergone any previous pelvic surgery adhesion could be one of the differential diagnosis. Any associated bleeding PR or haematuria can be due to endometriosis. If she is sub fertile this too would suggest either endometriosis or pelvic inflammatory disease. Her sexual history need evaluation to find out any high risk for STI.
Along with her general examination I will palpate for her abdomen for any tenderness or pelvic masses. The location of the tenderness and the palpable mass will give some idea about possible diagnoses. During speculum examination I will look for any abnormal discharges. If present it can be due to pelvic infection. During bimanual examination if cervical or adnexial tenderness will suggestive of pelvic infection. Tender and bulky uterus can be due to adenomyosis. In case of endometriosis, If bimanual examination is done during her menstrual cycle, endometriosis nodules can be palpable in the utero sacral ligament. However, most of the patient will not prefer to get examined during their menstrual period.
In chronic pelvic pain diagnostic laparoscopy is the gold standard investigation. However, it has its own inherent complication. This will diagnose endometriosis, pelvic infection or adhesion. The advantage of laparoscopy is while during the procedure treatment also can be done if patient had given already given consent.
Ultrasound will diagnose endometrioma, hydrosulpinx or any pelvic masses. MRI is not routinely used for this purposes. However, peritoneal infiltration can be diagnosed by MRI which would have been missed by ultrasound.
FBC will be normal in this patient who is with chronic pelvic pain. CRP normally increased during active phase of the disease. In endometriosis CA125 couldl be raised but the sensitivity and specificity are not significant.
In the process of treatment I will explain the findings to her. Before planning for the treatment I would like to find out what treatment was given by her GP. If she had not had the following treatment I would consider either combined oral contraceptive pills, Levenogesterol depot injection, danazol or GnRh antagonist. All these medication are equally affective. Side effect profile, cost of the treatment, and medical eligibility criteria need to be consider before commencing the treatment. COCP cannot be given if she is a smoker or if she has any other risk factors like thrombo embolism. Depoprovera (Levenogesterol) injections will cause irregular bleeding and in a long run it can cause osteoporosis. Danazon will cause hirsutism, breast atrophy and irreversible change of voice – hoarseness voice. Mirina IUS another option. It is a invasive procedure. When patient decides for progestogen infection she should be given information of irregular PV bleeding for 7 to 8 months. Eventually It can cause amenorrhoea.
If the patient is sub fertile surgical ablation of moderate endometriosis has proven benefit in improving pregnancy rate. It can be done either laparoscopically or by laparotomy. Laparoscopy has the advantages of less blood loss, less post operative adhesion early discharge home, quick recovery and less analgesia. However, we need an expertise to do this.
I will consider her psychological support for her.
Posted by milad A.
I will ask about pattern of pain as pain that is localised and sharp or burning likely to caused by nerve entrapment, and the associated symptoms for instance if associated with bladder filling and relived by voiding my indicate interstitial cystitis. I if bowel symptoms I enquire about abdominal bloating change in bowel habit, stool frequency and consistency and presences of mucous in stool and I will use Rom II criteria to diagnose Irritable bowel syndrome. I will ask about aggravating factors as pain that aggravate by postural change may suggest musculoskeletal cause. I will take her menstrual history regularity and volume ,as endometriosis can lead to menorrhagia and if her pelvic pain is cyclic, which would strikingly indicate gynaecological origin. However, 50% of irritable bowel syndrome has cyclic exacerbation. I will ask her subjectively how things in home and about sleep pattern and appetite. I will ask her sensitively about physical or sexual abuse particularly form intimate partner. I will take her past history of pelvic inflammatory disease and surgical history as adhesion can cause pelvic pain.
In pelvic examination if patient agree I will do it during menstrual period , I will look for tenderness uterine mobility and nodularity in uterosacarl ligament or pouch of douglas which would indicate endometriosis and I will look for adenxal masses.
I will ask her to fill in daily pain diary which will help in diagnosis and also to detect provoked factors. During pelvic examination if there is suspicion of pelvic infection I will take endocervial swaps for Chlamydia and gonorrhoea. Transvagional ultrasound will not help in diagnosis of endometriosis but it will make diagnosis of endomtrioma and in conjunction of MRI will assess diagnosis of adenmyosis. But MRI is not a diagnostic for endometriosis. CA 125 will be high in endometriosis, but it has low sensitivity. Laparoscopic , require proper counselling for possibility of negative result and serious risk of 0.6 and 1.8 /1000 risk of bowel and vascular injury and also risk of bladder and uterine injury and risk of death 1/100000. It gold standard for diagnosis of endometriosis but can not diagnosis condition like adenomyosis. And even endometriosis it may misdiagnosed deep infiltrative lesion as subtle lesion. Even though, It have advantage of diagnostic and treatment. Bowel study, such as barium enema will help in diagnosis inflammatory bowel diseases. Urine for microscopy and culture and sensitivity for typical and a typical organism.

Non steroidal inflammatory drugs may be effective in some woman with mild pain , they have risk of gastric ulceration and anovulation if taken in midcycle.
Hormonal treatments are all equally effective, but there adverse effect profiles are different and are not sutible if the woman want to conceive. Oral contraceptive, medroxyprogesterone acetate, danazole, gestrenon and GnRH analogues. all have recurrence rate after stop treatment. Danazole and GnRH used for short period due to their adverse effect but OCP can be used for longer period. GnRH analugoes used alone for 6 months only due to hypoestrogenic side effect and 6 % reduction of bone mineral density , with HRT add back can be used up to 2 years.
Surgical laprascopic applition and adhenolysis uauslly will be done at diagnostic laperscopy providing consent form is taken it is more effective than laperscopy alone.and extensive endometriosis require reveal to specialist center where expertise available
Posted by PAUL A.
Sanchu
Her severity of symptoms and how much they affect her quality of life should be asked for. Her detailed menstrual history, the onset, duration of pain question says 9 months , any radiation,any aggravating or relieving factors if these are relevant, you have to be specific – which factors will make you think endometriosis as opposed to say chronic PID? , association with bladder or bowel symptoms should be asked for which specific bowel symptoms? How would you diagnose IBS for instance? . Her sexual history should be obtained to find if she is high risk of PID ? is this the presentation for acute PID? . Her gynaecological history should be obtained to check if she was treated for PID (1) or endometriosis before. Her contraception history should be obtained ? any specific details? Just gynae Hx, obs Hx, contraceptive Hx… is not enough . Her obstetric history, any fertility problems, whether she has completed her family (1) should be asked for in order to plan management. Surgical history shoul be obtained to consider adhesions as a cause of pain
An abdominal examination should be done to look for tenderness, and palpable masses. A speculum examination may reveal vaginal or cervical endometriotic lesions or excessive vaginal discharge which may indicate PID do you get this in chronic PID? . Triple swabs should be done to help in diagnosis of PID asked about Hx and examination .
A bimanual examination would be to look for cervical excitation and adnexal tenderness in PID, a tender uterus in adenomyosis, nodules in POD and uterosacral ligament in endometriosis and for adnexal masses (1) .
B)Triple swabs to help in diagnosis of PID should be done what do they tell you about upper genital tract infection? . An ultrasonogram of the pelvis should be done. It helps in diagnosing adenomyosis, ovarian endometriomas, hydrosalphinx or tuboovarian mass in chronic PID. But a normal scan does not exclude endometriosis or adenomyosis (1) inflammatory markers, MRI, diagnostic laparoscopy .
C)Depending on her plans for fertility, the management would differ. If she is planning pregnancy, surgical management would be ideal since medical management precludes pregnancy ? simple analgesia . Laparoscopy, ablation of endometrial deposits (1) PAIN is the presenting symptom with a histological sample, ovarian cystectomy, adhesiolysis and restoration of normal anatomy and tubal flushing is done
If she does not want to become pregnant in the near future, she can be treated medically with continuous combined oral contraceptives, continuous progestogens, DMPA injections, GnRH analogues with add-back YOU WERE NOT ASKED TO WRITE A LIST – where is the discussion?? . Danazol is second -line due to androgenic side-effects and should not be used for more than 6 months.
LNG-IUS is an alternative (1) .
If there are endometriomas >4cm on ultrasound , although immediate fertility is not an issue, laparoscopic cystectomy is recommended followed by medical management.
Also, if symptoms do not resolve with medical management, laparoscopy is done.
Posted by PAUL A.
Chronic pelvic pain may have a single diagnosis responsible for it but could often be multifactorial. History would inlcude severity, frequency of pain and whether pain is associated with passing urine, deafecation or movement to rule out urinary, bowel or musculoskeletal problems this type of superficial Hx is not helpful. How, for instance, would you diagnose IBS? . A pain diary for 2 - 3 months/ menstrual cycle will be of help how does this help you? Just saying it will help is not enough . History would also include any past or present sexual assault psychosexual Hx , previous pelvic surgery or laparotomy and previous or present history of pelvic infection (1) .
Examination will include a thourough pelvic exam to elicit pain or nodularity of the uterosacral ligaments and adnexal masses or tenderness which may suggest endometrioma and endometriosis (1) respectively. Bulky uterus will point to possible fibroids or adenomyosis. Cervical excitation tenderness is likely positive for pelvic inflammatory disease is this the presentation of acute PID? . The flexibility of pelvic organs would assesss the severity of adhesions if present. Speculum exam will reveal any discharge.

Options for investigation will depend on likely differentials. If she has bowel related problems, input from gastroenterologists for further investigations would help. Urine can be cultured if necessary where does UTI appear in your list of possible diagnoses in a woman with a 9 months Hx of pain, dysmen & dyspareunia??? . Swabs would include chlamydial, gonoccocal and high vaginal for culture. This may however be negative in the presence of infection and treatment is indicated if high index of suspicion for infection. Pelvic ultrasound scan for adenomyosis has limited value is there anything else that scan can detect? Endometriomas, fibroids, value of normal scan.. . Magnetic resonance imaging not proven to be better in this regards.Laparoscopy is gold standard and second line of investigation for endometriosis what is your first line investigation to diagnose endometriosis? . Findings may be negative in presence of disease How? you mean surgeon missed it or a woman can have a normal pelvis and still have pelvic endometriosis??? . Extent of disease poorly correlates with severity of symptoms in case of endometriosis. Also gives opportunity for indentifying infection, adhesions and treament of endometriosis. laparoscopy also helps woman develop a belief about her pain what are the disadvantages of laparoscopy? CRITICALLY evaluate .

Treatment option for endometriosis are medical or surgical. Medical treatment will inculde use of combined oral contraceptive pills, progestogens such as depot medroxyprogesterone, implanon and levonorgestrel intrauterine system. Danazol and GnRH analogues are also useful you were asked to discuss, not LIST . Progestogens, danazol and GnRH analogues should nmot be used for more than 6 months why then are women using depot-provera for contraception permitted to use it for more than 6 months? . Progestogens can cause osteoporosis in long term users. Danazol can cause irreversible virilisation and adequate contraception required during its use. Pregnancy must be ruled out befores its use. GnRH analogue can cause post menopausal symptoms and add back therapy required if to ne used for more than 6 months (1) you have written nothing about simple treatments like simple analgesia / COCP . Failure of treatment with GnRH should trigger consideration of other diagnosisl do all women respond?? .Surgical treatment will include laser ablation or helium vapourisation of endometriotic lesions during laparoscopy (1) .This is helpful if infertility is an issue what about PAIN? That is the presenting problem . Hysterectomy and bilateral salpingo ophorectomy is last resort (1) with Hormone replacement therapy (1) . Women\'s chpice should be considered in treatment and consent taken for any surgical procedure. Support groups may help if pain persists.
Posted by PAUL A.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
a)Elaborate history regarding pelvic pain, its duration 9 months as stated in the question severity and effect on quality of life. its relation to menstruation, intercourse, bowel movement, urination. severity of dysmenorrhoea and whether it is progressive, progressive dysmenorrhoea that outlasts menstruation indicates endometriosis, while pain which preceds menstruation can be due to pelvic congestion secondary to adhesions or pelvic inflammatory disease(PID) is there any evidence that this assessment of pain is of any use in identifying the different possible causes? . history of hematuria urgency, urge incontinence indicate interstitial cystitis. history bowel disorders with agrevation or releif with dietary modifications may indicate irritable bowel syndrome what are the criteria for diagnosing IBS? A woman with inflammatory bowel disease could have symptoms that fit your description . history of pelvic surgeries ( pelvic abscess, endometrioma, ruptured ectopic) may hint towards pelvic adhesions leading pelvic congestion do you need adhesions to get pelvic congestion (if it exists)? . history of PID inthe past (1) . history of pain while passing stools or bleeding per rectum related to mensus indicates deep infiltrating endometriosis. history of infertility or infertility treatment/ no of conceptions and their outcome (endometriosis and PID associated with infertility) Desire for fertility (1) should also be asked since this also guides treatment. menstrual regularity is not affected in both endometrisis and PID. psychological issues like sexual abuse, history of sexual abuse as a child, domestic violance should be elicited (1) . examination looking for tenderness in suprapubic and iliac fossae pelvic examination would include a speculum and pervaginal examination, speculum examination may reveal lesions of endometriosis on vagina, cervix, posterior fornix, pervaginal examination showing nodularity in pouch of douglas, on uterosacral ligaments, lateral fornicial tenderness, retroverted fixed uterus, indicated endometriosis (1) .
b) pain dairy : maintaining a pain dairy ( for 3 months) of frequency of pain, association with bowel, bladder movements, menstuation, cyclicity may give a clear picture both to the patient and the doctor of the nature of pain. transvaginal ultrasonography (1) is highlt sensitive (90%) in detecting ovarian endometriomas however detection rate for peritooneal endometriosis is poor. diagnostic laparoscopy used to considered a gold standard for investigating cronic pain however now it is considered a second line if conservative and medical measures have failed women can be treated empirically, but laparoscopy remains the first line investigation if you want to diagnose endometriosis. IT IS NOT A SECOND LINE INVESTIGATION unless there is some other test that you will do in preference . laparoscopy helps indetecting peritoneal endometrisis and adhesions what are the disadvantages? CRITICALLY evaluate . if interstitial cystitis is suspected, cystoscopy shoud be considered. if deep infiltrating endometrisis is suspected IVP bariam enema MRI may have to be considered to know the extent of the disease. serum Ca 125 ha s poor sensitivity and not routinely used but may be used to identify women who need early laparoscopy. FBC, CRP, ESR
c) treatment depends of desire for fertility. if patient has completed family and is not keen on furthur issues medical managemnt of mederate endometriosis is effective. medical management involves inducing anovulation with either progesterones (continuous oral or depot injections of medroxy progesterone acetate) oral contraceptive pills ( continuous, sequential, tricyclic), danazol, gestrinone, GnRH anologues do not write a list – it is a waste of time and space and you get no marks. To write a list then go on to discuss individual treatments in detail is also inefficient . all of them have equal efficacy in controling the symtoms, however with different side effect profiles. danazol why start with this? It is at the bottom of the list of medical treatments causes virilization and hence not acceptable by some women, GnRH anologues causes menopausal symtoms and associated with osteoporosis if used for more than 6 months. however they can be used with add back with estrogen progesterone to prevent osteoporosis for upto 2 yrs (1) what have you written about COCP, the most likely drug that you will use????. all medical regimens are associated with recurrence after stopping the therapy which may occur in 6-12 month. laparoscopic uterosacral nerve ablation (LUNA) why not start with something useful like laparoscopic ablation??? may be considered after carful counselling since not much evidence is available to support its routine use. total abdominal hysterectomy and bilateral salpingoophorectomy with ablation of all the peritoneal disease is curative so you will tell this woman that you will do an operation, clear her pelvis and cure her??? . treatment of moderate endometriosis with desire for fertility would depend on the presence of ovarian endometrioma.treatment would be in vitro fertyilization and embryo tranfer after resection of the endometriotic cyst can she not fall pregnant on her own? .
Posted by PAUL A.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
a)Elaborate history regarding pelvic pain, its duration 9 months as stated in the question severity and effect on quality of life. its relation to menstruation, intercourse, bowel movement, urination. severity of dysmenorrhoea and whether it is progressive, progressive dysmenorrhoea that outlasts menstruation indicates endometriosis, while pain which preceds menstruation can be due to pelvic congestion secondary to adhesions or pelvic inflammatory disease(PID) is there any evidence that this assessment of pain is of any use in identifying the different possible causes? . history of hematuria urgency, urge incontinence indicate interstitial cystitis. history bowel disorders with agrevation or releif with dietary modifications may indicate irritable bowel syndrome what are the criteria for diagnosing IBS? A woman with inflammatory bowel disease could have symptoms that fit your description . history of pelvic surgeries ( pelvic abscess, endometrioma, ruptured ectopic) may hint towards pelvic adhesions leading pelvic congestion do you need adhesions to get pelvic congestion (if it exists)? . history of PID inthe past (1) . history of pain while passing stools or bleeding per rectum related to mensus indicates deep infiltrating endometriosis. history of infertility or infertility treatment/ no of conceptions and their outcome (endometriosis and PID associated with infertility) Desire for fertility (1) should also be asked since this also guides treatment. menstrual regularity is not affected in both endometrisis and PID. psychological issues like sexual abuse, history of sexual abuse as a child, domestic violance should be elicited (1) . examination looking for tenderness in suprapubic and iliac fossae pelvic examination would include a speculum and pervaginal examination, speculum examination may reveal lesions of endometriosis on vagina, cervix, posterior fornix, pervaginal examination showing nodularity in pouch of douglas, on uterosacral ligaments, lateral fornicial tenderness, retroverted fixed uterus, indicated endometriosis (1) .
b) pain dairy : maintaining a pain dairy ( for 3 months) of frequency of pain, association with bowel, bladder movements, menstuation, cyclicity may give a clear picture both to the patient and the doctor of the nature of pain. transvaginal ultrasonography (1) is highlt sensitive (90%) in detecting ovarian endometriomas however detection rate for peritooneal endometriosis is poor. diagnostic laparoscopy used to considered a gold standard for investigating cronic pain however now it is considered a second line if conservative and medical measures have failed women can be treated empirically, but laparoscopy remains the first line investigation if you want to diagnose endometriosis. IT IS NOT A SECOND LINE INVESTIGATION unless there is some other test that you will do in preference . laparoscopy helps indetecting peritoneal endometrisis and adhesions what are the disadvantages? CRITICALLY evaluate . if interstitial cystitis is suspected, cystoscopy shoud be considered. if deep infiltrating endometrisis is suspected IVP bariam enema MRI may have to be considered to know the extent of the disease. serum Ca 125 ha s poor sensitivity and not routinely used but may be used to identify women who need early laparoscopy. FBC, CRP, ESR
c) treatment depends of desire for fertility. if patient has completed family and is not keen on furthur issues medical managemnt of mederate endometriosis is effective. medical management involves inducing anovulation with either progesterones (continuous oral or depot injections of medroxy progesterone acetate) oral contraceptive pills ( continuous, sequential, tricyclic), danazol, gestrinone, GnRH anologues do not write a list – it is a waste of time and space and you get no marks. To write a list then go on to discuss individual treatments in detail is also inefficient . all of them have equal efficacy in controling the symtoms, however with different side effect profiles. danazol why start with this? It is at the bottom of the list of medical treatments causes virilization and hence not acceptable by some women, GnRH anologues causes menopausal symtoms and associated with osteoporosis if used for more than 6 months. however they can be used with add back with estrogen progesterone to prevent osteoporosis for upto 2 yrs (1) what have you written about COCP, the most likely drug that you will use????. all medical regimens are associated with recurrence after stopping the therapy which may occur in 6-12 month. laparoscopic uterosacral nerve ablation (LUNA) why not start with something useful like laparoscopic ablation??? may be considered after carful counselling since not much evidence is available to support its routine use. total abdominal hysterectomy and bilateral salpingoophorectomy with ablation of all the peritoneal disease is curative so you will tell this woman that you will do an operation, clear her pelvis and cure her??? . treatment of moderate endometriosis with desire for fertility would depend on the presence of ovarian endometrioma.treatment would be in vitro fertyilization and embryo tranfer after resection of the endometriotic cyst can she not fall pregnant on her own? .
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History and Examination. I will ask about the site and radiation of pain ,relieving factors like defecation which indicates inflammatory bowel diseases what are the symptoms of inflammatory bowel disease? Pain relieved by defecation??? Sounds like constipation and aggravating factors like pain while changing position which indicates adhesions suggests musculoskeletal pain rather than adhesions . A history of previous abdominal/ pelvic suggests ?? adhesions ,there may be associated subfertility which should be inquired about how does this help you? .Pain which starts on the first menstrual day and outlasts the whole cycle suggests
endometriosis not necessarily these characteristics are unhelpful .Associated symptoms of pain during defecation(dyschezia) and pain during micturation how many women with endometriosis have you encountered in whom pain on micturiction is a feature of their disease? also suggests endometriosis , however dysuria could be due to infection or iterstitial cystitis . A history of vaginal discharge suggests PID ?? acute PID with a 9 months Hx??? . I will sensitively and carefully ask about her sexual history, number of sexual partners and GUM treatment . I will ask ask about her parity, type of deliveries, last delivery and neonatal outcome .A careful history is taken about postnatal depression and domestic abuse/ voilence (1) .Details about treatment at G.P surgery is obtained (1) .
On examination I will asses her emotional and mental state and will look for any sign which suggests abuse/voilence .An abdominal examination is carried out for tenderness and masses .
A sterile speculum examination is carried out to asses the nature of discharge , purulent discharge from endocervix suggests PID /STI , swabs are taken for microbiology .Endometriosis may be visible as black , brown or red spots in vagina, posterior fornix or on cervix . I will perform a bimanual pelvic examination, a fixed retroverted tender uterus indicates endometriosis (1) . There could be nodularity in rectovaginal septum .
(B) Investigations
TVS is offered as it is noninvasive, easily available .can detect ovarian masses which suggests endometriomas .But it has low sensitivity in detecting pelvic and peritoneal endometriosis (1) .
MRI is usefull in dectecting severe and deeply infiltrated lesions but its role in detecting moderate and superficial endometriosis is not very helpful.It is expensivs ? more expensive than laparoscopy? , needs equipment and expertise does TVS not require equipment and expertise?? .
Laparoscopy is cosidered as gold standared for the diagnosis of endometriosis and adhesions, and can be used as therapeutic tool for adhesiolysis and ablation. However it can only detect superficial endometriosis.There are risks of laparoscopy like visceral and vascular injury (1) , post op shoulder tip pain infection . Expertise and equipment is needed waste of time – there is no investigation that does not require expertise .
(C) Treatment options are medical which could be non hormonal or hormonal and surgical treatment .Choice of treatment depends on her most distressing and cocerned symptoms like pain or subfertility and her wishes for a particular treatment . If her concern is only pain which has not been relieved with analgesics I will offer her combine oral cotraceptive pills continously (1) for 3-4 months why just 3-4 months?? . COCP supresses ovulation and inflammatory activity in the endometriotic spots thus effective in relieving pain . A therapeutic trial may be offered before diagnostic tests .COCP is associated with nausea ,vomiting, fluid retention. bloatedness and depression.
Gestrinone is weakly androgenic anti estrogen and anti progestogen.,Has less side effects than danazol and it effectively reduces endometriosis associated pain.
GNRH analogues (1) given as depots or nasal sprays supresses ovulation by supressing pitutary gonadotrophins .It causes osteoporosis if used for more than 6 months.There is a 6% loss of bone mass density by 6 months and may not recover completely.To prevent bone mass density loss addback therapy with estrogen and progestogens may be cosidered .
Danazol is another option ,it is effective in the treatment of endometriosis but has severe side effect profile like acne, hirsuitism, and masculinisation of female fetous ,so effective contraception is needed (1) .Dnazol increases bone mass density .
Laparoscopic adhesiolysis and ablation (1) of endometriotic spots is also effective in relieving pain and should be offered if medical treatment fails .
If womens concern is subfertility ,hormonal treatment is cotraindicated.Laparoscopic adhesiolysis and tubal flushing may improve pregnancy rate and should be offered .Before dignostic laparoscopy husbands semen analysis should be carried out . ? SIMPLE ANALGESIA, TAH + BSO
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a) The triad of pelvic pain, dysmenorrhea and dysparunea points to endometriosis ,however every effort should be done to explore other possibilities . Sympathetic approach to the patient is important to allow her to tell all her story and express her views regarding her complaint .She will be asked about nature of the pain, aggravating and relieving factors , whether it is cyclic or related to menstruation you have been given this information in the wuestion and areas of radiation how does this help you? . Specific sites and relation to movements will be asked for .Associated symptoms will be asked for through direct questions like urinary complaints in the form of frequency ,nocturia , urgency and dysuria . Bowel symptoms like bloating , change in the form of stools and dyschasia should not be missed (1) suggest IBS . Detailed menstrual history regarding cycle regularity ,dysmenorrhea pre or during or postmenstrual how will this help you?the question already tells you she has pain at other times and during menstruation . Contraceptive history (1) is important and current use of IUCD as it may be displaced . Whether she has used OCPs and their effect on the pain . Sexual history and number of partners or recent change of partner may give a clue to pelvic inflammatory disease is this the presentation of acute PID?? . Obstetric history regarding previous birth trauma or difficult delivery may indicate pelvic floor injury or spasm which obstetric injury will result in the symptom complex described? What is pelvic floor spasm??? . Infertility problems and future fertility wishes (1) are important in planning therapy .Previous drugs received (1) and any previous abdominal surgeries will be enquired about. I will examine her abdominally for specific sites of pain ,masses or scars . Pelvic examination for pelvic tenderness ,tender uterosacral ligaments , fixed tender uterus , any sign of infection in the cervix, and any pelvic masses(endometriomas) (1) .Examination during menstruation may be more informative if the woman consents to it .

b ) Investigation will include swabs for cultures& sensitivity if signs of pelvic infection are detected . The same applies for urine analysis if she has urinary complaints . Pelvic ultrasound is a good test for diagnosing endometriomas or otherpelvic masses but it has no role in diagnosing peritoneal disease (1) . MRI could be of benefit in diagnosing deeply infiltrating disease and verifying the nature of endometrioma but it is expensive more expensive than laparoscopy?? and not recommended for routine use . CA125 is not specific or sensitive for endomrtriosis but it can be high in severe cases (1) FBC, CRP, ESR. Barium enema and IVU should be done in case of suspected severe disease.
The gold standerd for diagnosing endometriosis is laparoscopy . Endometriotc spots or lesions could be seen and their location and extent identified and the presence of adhesions . Ideally biopsy will be taken for definitive diagnosis and exclusion of rare instances of malignancy(0.7%) . However there remains the risk of bowel and urinary injuries are in the range of 1-3 % DO YOU QUOTE A 1-3% RISK OF VISCERAL INJURY AT DIAGNOSTIC LAPAROSCOPY??? See notes on laparoscopy in GYNAE SURGICAL PRACTICE and mortality rate for diagnostic laparoscopy is 1/100000 .

c ) Options available for treating moderate endometriosis are either medical or surgical and depends on the patient choice and fertility wishes . Treatment of pain using NSAIs (1) is not of proven efficacy but some women may opt for it trying to avoid hormonal treatment . The same applies for alternatives like homeopathy and herbal medicine .
Hormonal treatment in the form of combined contraceptive pills or danazol or Gnrh agonists for 3-6 months WHY Should use of COCP be restricted to 3-6 months? That is the problem you face when you deal with 3 different drugs in the same sentence to suppress ovulation is of benefit for reducing endometriotic pain . OCPs can be used for long periods make your mind up – 3-6 months or longer??? but side effects of GNRH analogues especially the bone loss of6% bone mass in 6 months prevents their use more than 6 months unless addback low dose HRT is given simultaneously (1) The technique is simple – if there are 10 different drugs you deal with them individually to maximise your marks.
Levonorgestrel IUS (1) could be of benefit in reducing dysmenorrhea and pelvic pain .
Surgical treatment for moderate endometriosis ideally should be done with diagnosis of endometriosis during laparoscopy if informed consent is taken (1) . Removal of lesions using diathermy or laser or surgical excision together with adhesolysis is of definite effect in alleviating endometrial pain . The effect is not the same for minimal endometriosis did the question say she had minimal endometriosis? . Surgery should be done by experienced staff in a multidisciplinary system ? meaning?? Should the bowel and vascular surgeon be present in theatre??? as other organs like bowel may be affected or injured. Total abdominal hysterectomy and bilateral salpingooopharectomy is the most extensive surgery option and may be offered if all other options failed (1) ? HRT .
For patients with moderate endometriosis who are infertile , no clear evidence exists for the benefit of either hormonal or surgical treatment and they should be referred to an in fertility center for management.
Treatment of endometriosis could be frustrating and it takes time to accept the disease facts so sympathy and support groups are of great help to the patients.
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A) The woman on history should be asked for type of pain spasmodic or continous,radiation of pain to back(could be musculoskeletal) dysmen & DEEP dyspareunia could be musculo-skeletal?? lumbar region (ureteric colic,pyelonephritis) will you expect ureteric colic or pyelonephritis to present like this??????????? ,aggravating factors ,if aggravated on movement musculoskeletal in origin,relieving factors.any discharge per vaginum (PID),associated urinary complaint.like increased frequency ,burning during micturition(UTI) will UTI appear in your list of diagnoses in a woman with the symproms in question for 9 months?? , pain &hematuria(interstitial cystitis).Any associated bowel complaint like blood or mucus in stools,pain during defecation,increased frequency associated with particular food intake(inflammatory bowel syndrome) (1) .History of previous pelvic surgery,history of past or ongoing sexual abuse (1) .history of psychiatric illness especially depression.Patients menstrual history if menorrhagia(PID, fibroid uterus).Obstetrical history infertility would again point towards endometriosis.Sexual history number of sexual partners(multiple partners-PID).
On examination a general examination to note BMI. Thorough per abdominal examination to look for any abdominal masses ,per speculum examination to see for cervicitis ,vaginitis,mass arising from cervix vagina,discharge.Per vaginum examination to note size of uterus ,uterine tenderness,adenexal mass,thickened tender uterosacral (1) .

B)FBC as a part of routine investigation and would tell if any infection present CRP, ESR – markers of inflammation not just infection ,urine routine microscopic would show any urinary tract infection.Urine culture sensitivity if pus cells on routine. Cervical & vaginal swabs.Transvaginal sonography would show any mass in pelvis,though not very sensitive for adenomyosis (1) .MRI better in detecting adenomyosis,any other cause will it detect IBS?? . Patient with chronic pelvic pain diagnostic laparoscopy is the gold standard for investigation but complications of bowel perforation damge to major vessels need to be explained (1) ..

C)The treatment would depend on patients desire for fertility,severity of problem . Initial treatment with analgesics like naproxen (1) can be tried.If fertitilty not desired then patient can be given progesterone or combined oral contraception where is the discussion?/ .Danazol,gestrinone have androgenic side effects and cannot be given for a prolonged period (1) . Patient can be given LNG IUS (1) would be help but may cause irregular spotting and chances of expulsion there.

GnRH analogues can be given again not for prolonged period as cause osteoporosis(6% boneloss in 6 months)so should not be given for prolonged period not more than 6 months if given alone. With add back therapy (low dose oestrogen progesterone combination or tibolone ) can be for 2 years (1) .
.If desirous of children or not improving on medical treatment then laparoscopic surgical ablation (1) of of endometriotic implants, adhesiolysis,removal of endometriomas give good results and restores pelvic anatomy.patient to be referred to an infertility specialist
Lastly if unresponsive and fertility not required.then total abdominal hysterectomy with bilateral salpingoopherectomy (1) .if disease in rectovaginal septum resection should be done ? HRT .
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The above mentioned symptoms are sugggestive of endometriosis. However,Other conditions which may cause similar symptoms should be excluded by a detailed history and examination.
A thorough history should be taken with regards to the severity of symptoms and their impact on her quality of life.Specific questions relative to her pain such as cyclical/non cyclical you are given this in the question – she has cyclical pain (dysmen) and pain at other times (pelvic pain) , nature, such as sharp, dull or stabbing should be inquired about how does this help you distinguish between the possible conditions? . Any aggravating or relieving factors should be inquired about like what specifically? . The relation of pain to any bowel symptoms such as painful defecation, constipation or diarrhoea should be asked not enough – you need to be clear about the criteria for diagnosing bowel conditions like IBS . Similarly inquire about bladder symptoms such as dysuria, frequency ,hesitancy.Inquire about any associated vaginal discharge which is discoloured ,foul ,smelling or itchy/sore.
Inquire about any medical problems such as irritable bowel syndrome you may need to make the diagnosis or interstial cystititis or musculoskeletal pain or fibromyalgia , since the presence of any of those can contribute to her symptoms.
also inquire about previous surgeries such as caesarian section or laaprotomy for any other reason such as ovarian cysts since adhesions formation after surgeries can also complicate the picture due to adhesion formation. Similarly inquire about chronic PID or past history of chlamydia/ gonorrhoea infection (1) since it can also cause the above mentioned symptoms due to adhesion formation.
Inquire about parity, her desire to preserve fertility (1) .
Sensitively inquire about any psychological issues which be causing or compounding the problem psycho-sexual Hx .
Examination should include height, weight, blood pressure. Abdominal examination to look for any surgical scars, palpation of any abdominal masses.
Vaginal inspection for obvious endometriotic nodules, and an internal examination for mobility, size of uterus, cervical tenderness should be done. Palpate for any adnexal masses and palpable nodules suggestive od endometriosis in the POD (1) . Take endocervical swabs for chlamydia , gonorhoea and a high vaginal swab to rule out other infections such as bacterial vaginosis not asked about investigations in (a) .

B)
Transvaginal ultrasound is good at detecting adenomyosis ?? is it?? and endometriomas (1) but can not detect peritoneal endometriosis.
MRI ? limitations??? CRITICALLY evaluate or transvaginal ultrasound can also detect adenomyosis.
Laparoscopy is the gold standard for detecting endometriosis and chronic PID. Although deeply infiltrating endometriosis can be mistakenly diagnosed as mild disease.
Histology of the lesion at the time of laparoscopy can diagnose endomtriosis or but negative histology does not exclude it ? limitations of laparoscopy? CRITICALLY evaluate .
C)
Treatment options depend upon the severity of symptoms, their impact on the quality of life, the desire to retain fertility and her ovaries.The wishes of the patient is important in determining the type of treatment .
Medical management of her symptoms can be done by hormonal methods such as combined oral contraceptive pill (provivded there are no contraindications), progesterone danazol or GNRh analogues why deal with all these in the same sentence? to suppress the ovarian function for a period of 3 to six months with add back Tibolone or estrogen and progesterone will you use COCP for just 3-6 months and use add back therapy?? That is what you get when you address different drugs in the same sentence .
Levonorgestrel intrauterins system (1) can be tried to reduce the pain of endometriosis alongwith any associated menorrhagia.
Surgical option include laparoscoy and adhesiolysis, ablation of endometriotic deposits (1) , and cystectomy for endometriomas .
Complimentary therapies such as high frequncy TENs, reflexology or homeopathy can be tried if the patient is reluctant to go for medical or surgical treatment options.
Councelling for patients with psychological issues she has endometriosis, not psychological issues may be all that is needed or could be in combination with above mentioned therapeutic options.
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(PART A ) I will ask about severity of symptoms and its effects on her quality of life. I will ask about nature of pain (colicky,dull ache,burning), site,constant or intermittent the possible conditions are endometriosis, chronic PID, IBS / IBD, Psycho-sexual problems – how will these symptoms help you differentiate between these conditions? and its association with menstruation you are told this in the question and asked for ADDITIONAL information , micturition, defecation or any movement /posture. Any aggravating and relieving factor. I will ask about regularity of menstrual cycle, amount of bleeding (menorrhagia can be due to fibroid),cycle length,IMB or PCB. Regarding contraceptive history, use of IUCD(for PID), current use and future contraceptive wishes (1) . Regarding gynaecological history I will ask about history of vaginal discharge, sexually transmitted diseases and its treatment (1) (for PID0.History of subfertility, chronic fatigue, dysmenorrhoea, pelvic pain,dyspareunia repeating the question – you were asked about additional information ,dyschezia and cyclical hematuria/rectal bleeding are more suggestive of endometriosis.In obstetric history, parity of the woman, last child birth, any antenatal /postnatal complications,miscarriages, utrine instrumentation and TOP (more likely lead to PID). History of weight loss, alternating constipation/diarrhoea, bloating, rectal bleeding is more in favour of inflammatory bowel disease / irritable bowel syndrome(follow Rome criteria) the presentation of IBS and IBD are totally different and you cannot address them in the same sentence. You will not expect weight loss / rectal bleeding… in IBS .Urinary symptoms like frequency, urgency, bladder pain is more in favour of interstitial cystitis(IC).I will make sensitive enquiry about psychological and sexual abuse and any stressful events (1) .Symptoms like postcoital bleeding,wt loss,rectal bleeding and irregular periods are more in favour of neoplasm(ovarian). In examination I will check BMI.In abdominal examination I will check for abdominal distension,tenderness, rebound tenderness, any abdominal mass, palpable bladder. On speculum examination I will look for any discharge, any visible cervical / vaginal endometriosis spots (bluish spots) and take endocervical swabs. In vaginal examination(VE) I will check for uterine size, position and mobility (fixed retroverted ut in endometrioses) (1) . I will look for adenexal masses and tenderness. Deeply infiltrating endometriosis is best detected if examination done during menstruation depending upon women acceptance of VE during menstruation.

(Part B) USG is non invasive, good at detecting pelvic pathology especially if missed during clinical examination like ovarian mass, any other pelvic mass, fibroids and calculating risk of malignancy index. It is operator dependent and good quality equipment not necessary – clinical examination, laparoscopy…are all operator dependent and this is taken as is .It cannot diagnose peritoneal endometrioses (1) .Serum CA125 is increased in endometriosis,ovarian malignancy and in many other conditions,therefore less sensitive and specific as a screening/diagnostic tool alone.FBC white cell count and CRP are increased in inflammatory bowel disease (1) but further investigations like Colonoscopy/contrast studies should be undertaken by gastroenterologist. Laproscopy is gold standard investigation, it can diagnose pelvic endometriosis,pelvic masses, uterine adhesions and is also therapeutic (adhesiolysis and ablation of endometrotic spots) but it carries anesthetic/ operative risk like bowel, bladder, vessel damage (0.6 /1000 to 1.8 /1000) (1) .Laproscopy could also be normal so woman should be informed about it preoperatively.Deeply infiltrating nodules can be mistaken as minimal disease and IBS and adenomyosis cannot be detected.MRI is non-invasive,avoid surgery and can detect pelvic endometriosis /pelvic masses but there is insufficient evidence that it is a useful test to diagnose or exclude endometriosis compared to laparoscopy (1) . Urine dipsticks and MSU culture for (interstitial cystitis / UTI) will UTI feature in your list of diagnoses in a woman with these symptoms for 9 months? . Cystoscopy will be required for diagnosis of IC.

(Part C) Treatment options depend upon severity of the disease, previous treatment,her acceptance for treatment and woman’s concern whether she want pain management or infertility treatment. I will ask about the previous treatment history should have written this in your history (a) of women,whether she has taken NSAID/hormonal agents like COCP, progesterone and her compliance to treatment for at least 6months. If when you start setting conditions, you are following the wrong path. WHAT IF SHE HAS NOT TRIED ANY OF THESE? she has already taken this,then it is no more effective further this is not the place to discuss history – you were asked to discuss treatment options for a woman with moderate endometriosis .If fertility is not an issue and she accepts medical therapy for pain management , GNRHagonist (1) with addback therapy (estrogen and progesterone) for 2years is an option that protects against BMD loss at lumber spine during and for 6months after treatment has stopped.The postmenopausal symptoms were less severe with add back therapy and compliance required.Other option is LNG-IUS,it appears to reduce endometriosis associated pain (1) with symptoms control maintained over three years.Compliance is not a problem but associated with irregular bleeding for first 6months and breast tenderness.In Surgical option laproscopic ablation of endometriotic lesions (1) reduce the pain compared with diagnostic laparoscopy alone(63%improvement VS 23% in RCT) at 6months.Similarly surgical excision was associated with80% improvement in pain VS32% in placebo at 6months and this improvement in pain remains at 12month assessment except dyschezia.Presacral neurectomy may have some role if conservative laparoscopy has failed but it is more complex procedure and has greater morbidity.Hystrectomy and BSO is an option as a last resort (1) ,it reduces pain by removing entire lesion.But women will be informed that ideal regimen for HRT (1) after bilateral oophorectomy is unclear and will be given after assessment on indavidualized basis. YOUR ANSWER IS TOO LONG – YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE If fertility management is required ,suppression of ovarian function with hormonal agents has no place.The role of excisional/ablation surgery in improving pregnancy rates in moderate disease is uncertain.IVF is appropriate treatment especially if tubal function is compromised.There is also concern about cost and risk of multiple pregnancy/OHSS with IVF.Treatment with GNRH agonist for 3-6months before IVF increases pregnancy rate.Laproscopic ovarian cystectomy is recommended for endometriomas>4cm in diameter because it reduces infection risk,improves access to follicle/ovarian response and prevent endometriosis progression.There is also risk of reduced ovarian function/loss,so women should be counselled about it.I will provide written information of above discussion and address of support groups likeNational Endometriosis Society .
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a)
A history of pelvic pain ,dysmenorrhea and dyspareunia though suggestive of endometriosis, detailed history is enquired to rule out other causes. pelvic pain in relation to menstruation like dysmenorrhoea, menorrhagia is enquired you have already been told this in the question and asked for ADDITIONAL information . Bladder symptoms like dysuria, frequency is enquired to rule out urinary tract infection in a woman with a 9 months Hx of the symptoms in question?? . Bowel symptoms like change in the frequency, consistency of stools, difficult defecation to rule out irritable bowel syndrome is enquired what are the criteria for diagnosing IBS? .Symptoms of Pelvic inflammatory disease like lower abdomen tenderness ? symptom?? , any vaginal discharge, previous history of pelvic inflammatory disease (1) is enquired. History of back ache suggestive of musculoskeletal system is enquired. Past history of any pelvic surgeries for the same complaints or any other surgeries are enquired. Obstretic history in details regarding sub fertility or any treatments for conception is enquired.history of any contraceptive method (1) like Intra uterine device for pelvic inflammatory disease is enquired. Histroy of fever vomiting or localised abdominal tenderness like appendicitis 9 months Hx??? is enquired.
On examintaion; Last menstrual period details ?? examination , Per Abdomen examination for the site of tenderness, any mass papable in the pevis or lower abdomen is looked for. Also for guarding and rebound tenderness is looked for. Bimanual examination for uterine size, mobiity, tenderness, fornicial tenderness or any mass, nodularity in the pouch of douglas (1) is felt.
B)
Mid stream urine sample for microscopy and culture if required. Trans vaginal ultra sound for fibroid, adnexal mass and ovarian endometrioma. But absent of cystic structures do not exclude endo metriosis (1) . Laparoscopy is only reliable diagnostic test for for endometriosis. look for superificial endometriosis, adhesions, look for pouch of douglas. But depth of infiltration is related to the symptoms rather than the extent of involvement ? risks of laparoscopy – CRITICALLY evaluate . CA-125 is raised but it is neither sensitive or specific. MRI has role in diagnosing deep pelvic endometriosis. but for small deposits its role is uncertain (1) .
C)
Treatment depends on the symptom predominance:
Medical treatment : suppression of ovarian cycles for atleast 6 months is effective in controlling the pain. but symptom recurrence after stopping the treatment to be explained to woman. (50% recurrence within 1-2 yr of stopping treatment) Continued oral contraceptives ?? including progesterone-only?? helps by decreasing the pain, and has got good compliance , more useful in non smokers ? evidence that it is less effective / useful in smokers?? . Medroxy progesterone acetate (1) is also beneficial but side effects like acne,wt gain,mood swings has to explained. GnRH analogues with add back therapy (1) to improve pain and to protect form loss of bone mineral density for six months. Danazol is also effective has got anti estrogenic and anti progestogenic effect, immuno suppressive properties. after counseling the side effects like acne, oliy skin, wt gain (1) . advise about the need of contraception is done.
LNG IUS is also effective for dysmenorrhoea (1) and heavy menstrual bleeding, has additonal contraceptive benefits.
Surgical treatment; Adequate pre op counselling and consent has to be taken. Indicated if subfertiity is the concern as first line of treatment, pain improvement ,ovarian endometrioma ? meaning .
Ideal is laparoscopic surgery to excise the visible lesions or ablation using laser, or electro diathermy (1) . release of adhesions, cystecomy is carried out. Simultaneously tubal fiushing to improve the pregnancy rates. there is no role of pre or post op medicaltreatment for endometriosis. the role of presacral neurectomy and uterine nerve ablation is inconclusive.
conservative treatment is advocated only in asymptomatic woman is this woman asymptomatic?? .
Adequate counselling is required , patient self help groups provides invaluable support and advice. ? TAH + BSO
Posted by PAUL A.
M
(a) A history of severity of symptoms with quality of life affected, cyclical (perimenstrual pain) may suggest endometriosis she has dysmen and pelvic pain – that is pain without menses .
Bowel pain on movement or relief of symptoms on emptying bowel may suggest bowel related pain which bowel condition? / deep infiltrating endometrisis.
Bladder pain e.g. pain relieved on emptying bladder may suggest bladder cause for pain.
Her previous pregnancies and outcomes should be established as subfertility may suggest tubal disease.
Her detailed menstrual history may suggest need for treatment options for heavy bleeding along with pain control.
Her sexual history including number of partners and past history of any sexually transmitted infections (1) e.g. chlamydia may suggest cause for pain.
Details of treatment she had from GP (1) for her current symptoms may suggest need for alternate options.
General physical examination including pulse, BP, BMI as she may need a surgical procedure.
Abdominal examination to localise pain and exclude abdominal masses.
Speculum examination may reveal local vaginal or cervical endometrisis however this is rare and provides opportunity for endocervical and vaginal swabs if not done prior by GP.
Bimanual examination may reveal fixed, retroverted tender uterus/ tender uterosacral / rectovaginal nodules may suggest severity of endometriosis (1) , palpable ovaian mass may suggest endometrioma.

(b)Laparoscopy is the gold standard for diagnosis pelvic endometriosis, it helps to visualise and confirm diagnosis of peritoneal endometriosis, however needs to mobilise or palpate suspected deeper nodules and may not visualise deeper endometriosis. A positive histology will confirms endometriosis but a negative histology will not exclude the diagnosis. Laparoscopy has its own inherent risk of laparoscopic injuries like bowel, bladder and need general anaesthesia for the procedure (1) .
Transvaginal ultrasound or pelvic ultrasound has limited value in diagnosis endometriosis compared to laparoscopy, howvever is useful to exclude diagnosis of ovarian endometrioma when clincally suspected (1) .
CA125 may be elevated with endometriosis but has no diagnostic value no value??? compared with laparoscopy.
If clinically suspected with significant endometriosis like ureteric / bladder involvement or rectovaginal nodules then MRI, IVP and barium enema studies as appropriate for mapping extent of disease may help before considing surgical treatment ? value of MRI as primary investigation for endometriosis / adenomyosis .

(c)This depends on patients wishes including her fertility choices.
Medical treatment options include ovarian function suppression with combined oral contraceptive pills as a therapeutic trial why is it a therapeutic trial? You have already been given a diagnosis. A therapeutic trial is when you treat someone without a positive diagnosis. Improvement confirms the diagnosis for atlest 6 months may suppress endometrisis but likely to recurr on stopping treatment why should COCP be stopped after 6 months when women use it for contraception for decades?? , sideeffects like bloatedness, breast tenderness, mood changes should be explained
Alternatively medoxyprogesterone acetate (1) can be used in those not suitable for oestrogen again with side effect profile explained.
Mirena coil (1) is effective in controlling pain related to endometriosis and also helps in reducing heavy menstrual bleeding.
GnRH analogue with add back HRT is a useful treatment for upto 6 months why only 6 months if you are giving add back HRT??? .
Danazol and Gestrinone are useful in treatment but their side effect profile like androgen effects limits its use (1) .
Laparoscopic surgical ablation/ removal of visible endometriosis (1) is a treatment option howerver, may need complex surgery with MDT including surgeons, urologist for deeper infiltrating disease and available only in certain centres.
Ovarian endometrioma of more than 4 cms should be removed to confirm diagnosis and exclude underlying malignancy, but risk of oopherectomy.
If tubal factor is suspected with endometriosis, tubal flusing may improve fertility rates.
Bilateral oopherectomy with HRT why leave the uterus behind? is an alternative option if no fertility wishes in future and depending on severity of disease.
If tubal disease and fertility affected may need IVF as treatment option.
Other treatment with complimentary therapies have no evidence as treatment option.
She should be provided with information leaflets and details of support groups.
Posted by PAUL A.
shalini
a)It is emperative to begin bysympathetically listening to the complaints of this ladyand then taking a detailed history of pain-whether it is cyclical or continous you are given this information in the question: dysmen = cyclical + pelvic pain = pain at other times. You are asked about ADDITIONAL information ;any aggravating or relieving factors and any relation to movement or posture how will this help you? .Any previou history of PID is important as she could be suffering from chronic PID (1) .Also a detailed menstrual history-frequency,duration of bleeding as also history of IUCD usage in the past and present contraceptive in use (1) as use of IUCD in the past could also be responsible for chronic PID.Obstetric history of this lady is important-whether she has previous normal births or cesarean sections as adhesions also can cause pevic pain have you ever seen a woman with chronic pelvic pain caused by adhesions following CS?? .Any history of sexual abuse or psychological problems (1) must be enquired into.Any urinary complaints should be asked for like bladder pain,urgency and frequency as interstitisl cystitis could also be causative of pelvic pain.Also bowel complaints like constipation,diarrhoea,distensionand weight loss should be enquired into to rule out any irritable bowel syndrome or inflammatory bowel disease as the cause IBS and IBD are very different conditions with different symptoms. How does the examiner know that you know which symptoms are specific for IBS or IBD?? .On examination,abdominal distension,tenderness,rebound tenderness,presence of mass should be looked for.on pelvic examination,cervical motion tenderness ,uterine size,mobility,tenderness,adnexal mass,tendernessas also tendrness or palpating nodules along the uterosacral ligament should be noted (1) .Also a rectal examination is done to palpate tender nodules along uterosacral ligament.
b)Transvaginal ultrasound has a sensitivity of 65%-68% and a specificity of 68%-95% for adnexal masses You are being ‘too clever’ and lose marks – are you suggesting that only 65-68% of adnexal masses will be picked up by TV scanning?? and ovarian endometriosis can be picked up. Also MRI can diagnose peritoneal endometriosis as also uterine pathology with a sensitivity of 70-85% and specificity of 85-88% not clear where you got your figures from but you will not remember them in the exam. The sensitivity you quote – is it for endometriosis or uterine pathology or both? What is uterine pathology? .Gold standard of diagnosis is diagnostic laproscopy as small peritoneal endometriosis can be picked up.However adenomyosis and conditions like inflammatory bowel disease can be missed and also there is no pathology found in atleast 15% of laproscopies.They have a risk of death 1/10,000 and 2.4/1000 of risk of visceral and vessel injury (1) with two-thirds of them requiring laprotomies that must be explained to the lady.Use of conscious pain mapping during laproscopy is becomin popular to find out the exact cause of pain.If gynaecological and non-gynaecoogical cause of pain cannot be distinguished on the basis of history and examination then GnRh analogues can be used to suppress ovarian activity and if relief is experienced it is gynaecological. THERE ARE 4 MARKS FOR (b) AND 10 MARKS FOR (c) – COMPARE THE TIME / SPACE YOU HAVE DEDICATED TO THESE COMPONENTS. IRRESPECTIVE OF WHAT YOU WRITE, YOU WILL NOT GET MORE THAN 4 MARKS FOR (b)
c)Treatment options can be decided upon her most important complaint.If she wants pain relief NSAIDs (1) can be used as also co-co-cydramolol that has been found to be effective. Uterine nerve ablations you are writing about treatment for endometriosis and you jump from simple analgesia to uterine nerve ablation with nothing in the middle???? have not been found to be very effective in pain relief.If she wants contraception then combined contraceptive pills ca be precribed as they suppress ovarian activity and are effective in pain due to endometriosis (1) .Also danazol can be used but due to androgenic side-effects this is not preferred (1) so why not write about something that is more commonly used next?? .Gnrh analogues can be used if pain is not relieved with any prescription ? meaning but risk of side-effects of estrogen deficiency should be explained as also irreversible bone-loss is there anything that can be done about this? .If she wants conception then IVF should be offered as there is no role of IUI and ovarian stimulation.She should be adequately counselled about risks of IVf like multiple pregnancy,ectopic pregnancy and ovarian hyperstimulation syndrome that acn occur.Presence of hydrosalpinx has an adverse effect on outcome of IVF and should be removed before it.Also ovarian endometrioma more than 4 cm should be removed to relieve symptoms and for histological confirmation of diagnosis. Your priorities are inappropriate – treatment for endometriosis: simple analgesia, COCP, progestogens, GnRH analogues + add back; laparoscopic ablation / resection, TAH + BSO + HRT. After that, you can write about anything else if you have time and space
Posted by PAUL A.
Sunday\'s answer

a)I would ask about the pattern of the symptoms- if its cyclical you are given this in the question: dysmen = cyclical, plus pelvic pain = pain at other times with associated symptoms like menorrhagia, backpain and bowel symptom such as constipation, change in bowel habit if this is all your GI Hx then you will not diagnose IBS . I would also exclude any urinary symptoms such as frequency, urgency, dysuria. A family history of endometriosis would be explored and information about how the symptoms is affecting her quality of life. I would also ask about previous gynaecological operation with indication and outcome.On examination i would check for any tenderness or palpable mass on the abdomen, previous scars from past surgeries and a pelvic examination to demonstate any adnexal tenderness or palpable mass. A rectal examination may be indicated for deep infiltarting lesion affecting the rectum (1) .

the possible diagnoses are: endometriosis, chronic PID, adenomyosis, IBS / IBD, psychosexual problems. Which information have you obtained from your Hx that will help you differentiate these conditions? You did not even ask which treatment she has been given by her GP!

b) A triple swab may be indicated to rule out any infective cause though this is unlikely so this is near the bottom of your list of possible diagnoses – so why start with it? . A Pelvic scan may be indicated particularly if a mass is suspected in the abdomen or pelvis. A normal scan may not rule out the presence of endometriosis and small lesion may not be picked up on scan (1) . Diagnostic laparoscopy is the gold standard but in about 20% of patients a negative finding at laproscopy may be the case ? complications – CRITICALLY evaluate .

c) Options include a conservative approach where by symptoms are treated with painkillers like what? Your answer must be detailed. This is a postgraduate and competitive exam depending on the severity of the symptom and patients preference. Other option include the use of Hormonal preparation such as the combined pill (1) which can be back to back. Progesterone in form of Mirena ius (1) what about oral progestogens? has shown some benefit in some patients. Danazol has some benefits but the major draw back is the side effect what are the side-effects? . The GnRH analogue such as zoladex can be tried but not for more than 6 months with add-back HRt such as tibolone are you suggesting that GnRH + add back should not be used for more than 6 months?? . Surgical option may be required if the above option has failed and this will require laparoscopy and excision of the endometritic spots (1) ? ablation, TAH+ BSO ? HRT may be required depeding on the severity of her symptoms and future desire for fertility.

You have used about half as much space & time as everyone else and that is worrying. With the level of knowledge you have, you could still pass the exam if you recognise the need for detail.
Posted by PAUL A.
A 37 year old woman has been referred to the gynaecology clinic with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia that has not responded to empirical treatment by her general practitioner. (a) Discuss what additional information from the history and examination is helpful in establishing a diagnosis and treating the woman [7 marks]. (b) Critically evaluate the options for investigating her symptoms [4 marks]. (c) She is found to have moderate endometriosis. Discuss the treatment options available [10 marks].
C
The diagnosis is chronic pelvic pain this is not the diagnosis – it could be endometriosis… which can cause physical, social and psychological effect on this patient. Her symptoms could be due to Endometriosis, Chronic pelvic inflammation or adhesion. Rarely it can be due to non gynaecological condition. Keeping this in mind I will focus my history to this patient just answer the question – the examiner is not interested in your thought processes .
In the history I will asses how her symptoms affects her personal, social, psychological and professional life.
Any previous pelvic infection or treatment of STI (1) would suggest she may suffer from chronic pelvic inflammatory disease. If she had undergone any previous pelvic surgery adhesion could be one of the differential diagnosis. Any associated bleeding PR or haematuria can be due to endometriosis. If she is sub fertile this too would suggest either endometriosis or pelvic inflammatory disease. Her sexual history need evaluation to find out any high risk for STI. ? psycho-sexual problems. You have not asked which treatment her GP gave her. Symptoms of IBS / IBD
Along with her general examination no marks for general examination so do not waste your time / space I will palpate for her abdomen for any tenderness or pelvic masses. The location of the tenderness and the palpable mass will give some idea about possible diagnoses. During speculum examination I will look for any abnormal discharges. If present it can be due to pelvic infection. During bimanual examination if cervical or adnexial tenderness will suggestive of pelvic infection. Tender and bulky uterus can be due to adenomyosis. In case of endometriosis, If bimanual examination is done during her menstrual cycle, endometriosis nodules can be palpable in the utero sacral ligament (1) . However, most of the patient will not prefer to get examined during their menstrual period.
In chronic pelvic pain diagnostic laparoscopy is the gold standard investigation. However, it has its own inherent complication (1) what are the complications??. This will diagnose endometriosis, pelvic infection or adhesion. The advantage of laparoscopy is while during the procedure treatment also can be done if patient had given already given consent.
Ultrasound will diagnose endometrioma, hydrosulpinx or any pelvic masses ? limitations?? CRITICALLY evaluate . MRI (1) is not routinely used for this purposes. However, peritoneal infiltration can be diagnosed by MRI which would have been missed by ultrasound.
FBC will be normal in this patient who is with chronic pelvic pain. CRP normally increased during active phase of the disease. In endometriosis CA125 couldl be raised but the sensitivity and specificity are not significant (1) ? value in inflammatory bowel disease .
In the process of treatment I will explain the findings to her you were asked to discuss treatment options and this does not mean discuss them with the woman – it is simply an exam question . Before planning for the treatment I would like to find out what treatment was given by her GP you were given the opportunity to write this in (a) . If she had not had the following treatment I would consider either combined oral contraceptive pills, Levenogesterol depot injection, danazol or GnRh antagonist do not write a list – you will not get any marks . All these medication are equally affective (1) . Side effect profile, cost of the treatment, and medical eligibility criteria this again is a waste of time – how does the examiner know that you know the side-effects, costs… of the different treatments? need to be consider before commencing the treatment. COCP (1) cannot be given if she is a smoker or if she has any other risk factors like thrombo embolism. Depoprovera (Levenogesterol is depoprovera levonorgestrEL?? ) injections will cause irregular bleeding and in a long run it can cause osteoporosis SO WHY DO 37 YEAR OLDS USE IT FOR LONG-TERM CONTRACEPTION?? . Danazon will cause hirsutism, breast atrophy and irreversible change of voice – hoarseness voice (1) . Mirina IUS (1) THIS IS LEVONORGESTREL another option. It is a invasive procedure. When patient decides for progestogen infection she should be given information of irregular PV bleeding for 7 to 8 months ???? . Eventually It can cause amenorrhoea.
If the patient is sub fertile surgical ablation of moderate endometriosis has proven benefit in improving pregnancy rate does it do anything for her pain? . It can be done either laparoscopically or by laparotomy have you seen anyone do laparotomy with the aim of ablating endometriosis?? . Laparoscopy has the advantages of less blood loss, less post operative adhesion early discharge home, quick recovery and less analgesia. However, we need an expertise to do this do you not need expertise to do a laparotomy or a vaginal examination?? .
I will consider her psychological support for her.
Posted by PAUL A.
I will ask about pattern of pain as pain that is localised and sharp or burning likely to caused by nerve entrapment is nerve entrapment on your list of differential diagnosis for a woman with a 9 months history of pelvic pain, dysmenorrhoea and deep dyspareunia??? , and the associated symptoms for instance if associated with bladder filling and relived by voiding my indicate interstitial cystitis. I if bowel symptoms I enquire about abdominal bloating change in bowel habit, stool frequency and consistency and presences of mucous in stool and I will use Rom II criteria to diagnose Irritable bowel syndrome (1) . I will ask about aggravating factors as pain that aggravate by postural change may suggest musculoskeletal cause is this a possible diagnosis in this woman? . I will take her menstrual history regularity and volume ,as endometriosis can lead to menorrhagia and if her pelvic pain is cyclic you are told this in the question and asked for ADDITIONAL information , which would strikingly indicate gynaecological origin. However, 50% of irritable bowel syndrome has cyclic exacerbation. I will ask her subjectively how things in home and about sleep pattern and appetite. I will ask her sensitively about physical or sexual abuse (1) particularly form intimate partner. I will take her past history of pelvic inflammatory disease (1) and surgical history as adhesion can cause pelvic pain.
In pelvic examination if patient agree I will do it during menstrual period , I will look for tenderness uterine mobility and nodularity in uterosacarl ligament or pouch of douglas which would indicate endometriosis and I will look for adenxal masses (1) .
I will ask her to fill in daily pain diary which will help in diagnosis how will it help? and also to detect provoked factors. During pelvic examination if there is suspicion of pelvic infection I will take endocervial swaps for Chlamydia and gonorrhoea WHERE DOES PART (b) OF YOUR ANSWER START? . Transvagional ultrasound will not help in diagnosis of endometriosis but it will make diagnosis of endomtrioma does a woman with an endometrioma not have endometriosis??? and in conjunction of MRI will assess diagnosis of adenmyosis. But MRI is not a diagnostic for endometriosis ?? poor English . CA 125 will be high in endometriosis, but it has low sensitivity. Laparoscopic , require proper counselling for possibility of negative result and serious risk of 0.6 and 1.8 /1000 risk of bowel and vascular injury and also risk of bladder and uterine injury and risk of death 1/100000 (1) . It gold standard for diagnosis of endometriosis but can not diagnosis condition like adenomyosis. And even endometriosis it may misdiagnosed deep infiltrative lesion as subtle lesion. Even though, It have advantage of diagnostic and treatment. Bowel study, such as barium enema will help in diagnosis inflammatory bowel diseases. Urine for microscopy and culture and sensitivity for typical and a typical organism.

Non steroidal inflammatory drugs (1) may be effective in some woman with mild pain , they have risk of gastric ulceration and anovulation if taken in midcycle.
Hormonal treatments are all equally effective, but there adverse effect profiles are different and are not sutible if the woman want to conceive (1) . Oral contraceptive, medroxyprogesterone acetate, danazole, gestrenon and GnRH analogues do not write a list – deal with these one at a time to get maximum marks . all have recurrence rate after stop treatment. Danazole and GnRH used for short period due to their adverse effect do they have the same adverse effects? but OCP can be used for longer period (1) . GnRH analugoes used alone for 6 months only due to hypoestrogenic side effect and 6 % reduction of bone mineral density , with HRT add back can be used up to 2 years (1) .
Surgical laprascopic applition ?? and adhenolysis uauslly will be done at diagnostic laperscopy providing consent form is taken (1) it is more effective than laperscopy alone.and extensive endometriosis require reveal to specialist center where expertise available ? TAH + BSO + HRT
Posted by PAUL A.

Most candidates had difficulties with this question.

(a) You have been given a substantial portion of the history (9 months, pelvic pain, dysmenorrhoea [which is cyclical pain] and deep dyspareunia; no response to treatment by GP). You are asked for ADDITIONAL information from Hx and examination.

Your ability to take a general gynae Hx is not being tested.

Start by writing your list of differential diagnoses [in your answer plan]: endometriosis, chronic PID, adenomyosis, IBS / IBD, psycho-sexual problems.

Then ask yourself which info you can get from the Hx / exam to help you make a definitive diagnosis.

Nature of pain (dull / stabbing…) radiation (into her thighs, back…) whether it starts the day before or the day after het period… does not help you.

You may come up with 20 different things you want to ask in the Hx. However, you do not have 5 pages or 20 marks. You therefore need to decide the most important things that will help you make a diagnosis or treat the woman.

You cannot treat the woman if you do not ask her about the treatment she has already taken.

You must be detailed and specific. If you believe that radiation of pain / nature of pain will help you then state how.



A good answer should include the following

(a)
History
• Bowel symptoms: Know criteria for diagnosis of IBS. Weight loss, bloody diarrhoea and mucus may indicate inflammatory bowel disease (1 mark)
• Past history of PID – chronic PID is a possible cause (1 mark)
• Current and previous contraception: IUCD associated with dysmenorrhoea while symptoms may appear after stopping COCP (1 mark)
• Previous treatments and any benefits / side-effects (1 mark)
• Psycho-sexual history – psycho-sexual problems may present with dyspareunia and chronic pelvic pain (1 mark)
• Parity and whether her family is complete / trying to conceive (1 mark)

Examination
• Abdomino-pelvic mass, fixed retroverted uterus and presence of nodules in the pouch of Douglas suggests endometriosis. Lesions may also be present in the vagina or on the cervix (1 mark)
• Perineal induration / fistulae; anal fissures indicate inflammatory bowel disease (1 mark)

(b)
• Blood tests: FBC / ESR or CRP indicate inflammatory process as in inflammatory bowel disease. Elevated CA-125 may indicate endometriosis and identify women for invasive investigation (1 mark)
• Abdominal / pelvic ultrasound scan – normal scan may be reassuring. However, may not detect mild – moderate endometriosis / chronic PID or inflammatory bowel disease. Non-invasive and readily available (1 mark)
• Further imaging like MRI may provide diagnosis without invasive investigation. Cheaper compared to laparoscopy but may miss mild endometriosis / chronic PID (1 mark)
• Diagnostic laparoscopy is the gold standard investigation but associated with risk of visceral injury. Will not identify functional disorders such as IBS. Non specific findings like adhesions / minimal endometriosis may wrongly be identified as the cause of her symptoms (1 mark)

(c)

Treatment options for moderate endometriosis
• NSAIDS – may be used but there is little evidence that they are effective. Have GI side-effects and anti-ovulatory effects when taken mid-cycle (1 mark)
• Hormonal treatments are equally effective but have different side-effect profiles. Do not alter biological course of the disease and symptoms typically recur after stopping treatment (1 mark)
• COCP – may be used cyclically, tri-cyclic or continuously. Contraindicated if the woman is a smoker, has focal migraine or personal history of VTE (1 mark)
• Medroxyprogesterone acetate should be used in sufficient doses to cause amenorrhoea but associated with progestogenic side-effects (1 mark)
• Danazol associated with androgenic side-effects such as acne, hirsutism and deepening of the voice which is irreversible (1 mark)
• GnRH analogues associated with menopausal symptoms and loss of bone mineral density if used beyond 6 months. HRT add-back therapy may be used to prolong treatment (1 mark)
• Levonorgestrel IUS shown to reduce endometriosis-associated pain over 3 years (1 mark)
• Laparoscopic ablation of endometriotic lesions shown to reduce pain but should only be undertaken at the time of diagnosis if appropriate consent had been obtained pre-operatively. (1 mark)
• If symptoms persist, TAH + BSO may be required and post-operative HRT is recommended. Major surgery associated with significant morbidity and chronic pelvic pain may persist. (2 mark)
Posted by Nur Sakina K.
NSK

From A:
Severity of symptoms and impact on quality of life(QOL) is addressed for degree of bother to her. Any associated bowel (dyschezia, bleeding), urinary (dysuria) heavy menses, sexual difficulties is vital to exclude other causes of her symptoms. Her parity and future fertility desires is important as affects treatment options. Current contraception use will assess future needs and whether it’s an option for managing symptoms (COCP, mirena IUS). Symptoms- weight loss, rectal bleeding, mass noted suggests malignancy although unlikely in her age group. Past medical history- bowel problems (irritable bowel syndrome) pelvic inflammatory disease (PID), cardio/respiratory condition is vital to exclude chronic presentation and any comorbid disease that affects treatment options. Past surgical history-laparoscopies, laparotomy helps address any possible difficulties if surgery offered. Previous treatment for symptoms is elicited to guide future treatment.
BMI and observations (blood pressure, pulse, temperature, respiration) for baseline levels and possible difficulties at surgery is recorded. Abdominal examination for masses suggesting fibroids, adenomyosis; site of tenderness and presence of rebound or rigidity suggests peritonitis. A bimanual examination for fixed, retroverted uterus and nodules suggests endometriosis. Adnexal tenderness for pelvic congestion syndrome and an enlarged uterus for possible fibroids/ adenomyosis can be assessed. If bowel symptoms present, PR examination can identify nodules suggesting endometriosis.

From B:
Urine sample for microscopy, culture and sensitivity identifies urinary tract infection (UTI) or cystitis (hematuria). Vaginal swabs ( high vaginal, endocervical) during pelvic exam useful to exclude PID. Bloods for full blood count (elevated leucocytes) suggests PID, UTI although its absence does not exclude this. Elevated inflammatory markers (ESR, CRP) although nonspecific may suggest PID. CA125 can be elevated in endometriosis , but is nonspecific and elevated in other conditions (inflammatory bowel disease, ovarian cancer). Imagings- transvaginal and transabdominal ultrasound scan may be useful to identify fibroids, endometrioma. An MRI can identify deeply infiltrating endometriotic nodules, although not routinely done. If urinary symptoms present, a cystoscopy helps exclude cystitis. A diagnostic laparoscopy is warranted as empirical treatment has failed. It helps identify endometriosis and any ovarian pathology.

From C:
Treatment will depend on her wishes, presence of comorbid conditions, and fertility desires. Surgical treatment is most likely needed as empirical treatment has failed. Laparoscopy with endometriosis ablation +/- adhesiolysis should be offered. It helps relieve pain due to endometriosis. However, the risk of recurrence and repeated procedures needed in the future must be explained. If endometrioma is identified, this should be removed and possibility of oophorectomy must be explained. Total abdominal hysterectomy with bilateral oophorectomy (TAH, BSO) should be considered as a last resort if all other measures has failed and fertility is not an issue. She will need hormone replacement therapy if this were done, to avoid menopausal symptoms. If she does not want surgery, medical treatment combined oral contraceptive pill (COCP), mirena IUS or GnRH analogues can be offered. All medical treatments are equally effective and differ in terms of its side effect profile. Use of GnRH analogues should be limited to maximum of 6 months due to its effect on bone (osteoporosis) although add back therapy with estrogen, progestogen can prolong use upto 2 years in some cases. Side effects of hot flushes and other menopausal symptoms should be explained. Symptoms recurrence can occur once stopped. Simple lifestyle measures- weight loss (if obese), avoiding alcohol, smoking, caffeinated drinks may help improve general wellbeing. Information leaflets are given to allow her to make an informed decision regarding treatment.
Posted by Nur Sakina K.
sorry paul, i take forever to type up my answers, by the time i posted my answer, u had put the model answer on already!
sorry again!
Posted by Ron C.
Same here, I\'d written the answer before the model answer came out, but only tonight got to type it.... would still really appreciate markings.... thanx heaps dr Paul

RnRn

A.
The extent in which it affects her quality of life and what she has tried so far may determine the management. Exact location and nature of pain may help to determine the cause. Information regarding cycle and LMP must be known. Pain increasing towards onset of period and then subsiding is suggestive of endometriosis. Type of current and past contraception is important as hormonal contraception often improves endometriosis complaints. Obstetric history but especially plans for fertility could affect management. Presence of vaginal discharge or history of unprotected intercourse with multiple partners can point to possibility of chronic pelvic inflammatory disease (PID). Problems regarding passing urine or stools could point to non-gynaecological causes such as interstitial cystitis, irritable bowel syndrome or inflammatory bowel disease. History of previous surgery can point to possible adhesions.
Examination includes blood pressure and pulse rate as part of possible pre-op assessment. General inspection, noting scars of previous surgery. Abdominal palpation may identify a pelvic mass and location of tenderness may aid in diagnosis. Speculum examination to assess abnormal discharge and take triple swabs for sexual transmittable disease. Vaginal examination may reveal pelvic mass, enlarged (fibroid) uterus, cervical excitation or fixed retroverted uterus as in endometriosis. Endometriosis nodules may be felt in posterior fornix.

B.
Triple swabs may identify sexual transmittable disease, but even in presence of chronic PID they may be negative. Bloods for CA125 can show raised levels, but this is highly a-specific as it can be raised in many conditions. Nevertheless it could assist in decision for laparoscopy if also abnormal ultrasound findings are noted. Ultrasound cannot identify PID or endometriosis, but it can show enlarged uterus in adenomyosis or fibroid and it may reveal an endometriotic cyst or tubo-ovarian abcess.

C.
If impact of life is minimal and patient merely worried, conservative management with reassurance may be all that is needed. If patient is very symptomatic but keen to conceive, treatment is restricted as most forms will interefere with fertility. In absence of further abnormalities conservative management is appropriate. If fertility is thought to be compromised, she must be refered to the fertility team.
Medical management is appropriate for those not keen to conceive. Possibilities are the combined oral contraceptive pill, either cyclical or continuous. Alternatives are the mini-pill, depot medroxy progesterone or implanon. Mirena coil also often offers improvement. Alternate medical treatment is by means of GNRH- analogues such as zoladex, but this is not a long term solution as it can only be used up to 6 months.
Surgical approach, mostly in form of laparoscopy is appropriate in those who were seen to have endometrioma; removal of endometrioma can result in improvement of complaints. At the same time extent of disease can be noted and cauterization of endometriosis spots performed. It may also be used to assess those who are keen to conceive and tube dye tests can be done at the same time. Most extreme form of surgery would be bilateral ovariectomy, but as it would cause her to go into early menopause, it is only suitable as very last option after trial of GNRH-analogues
Posted by A H.
AH
Cyclical pain or pain exacerbated by menses suggests a gynaecological cause. there may be associated painful defecation, or bleeding per rectum during the menses in endometriosis.
I will like to know the site of the pain and if there is any radiation, associated change in bowel movement or urinary symptoms and if it is exacerbated by change in posture.
A past history of Pelvic Inflammatory Disease (PID) , abdominal or pelvic surgery will be asked. Adhesions due to PID or surgery can cause chronic pelvic pain.
I will examine the abdomen for tenderness, guarding and rebound tenderness. I will palpate for an abdominal mass and associated tenderness.
A speculum examination will be done to detect any abnormal discharge suggestive of PID, or endometriotic deposits.
At bimanual examination uterine size, tenderness and mobilitywill be assessed. The uterosacral ligaments will be palpated for tenderness or nodularity. Adnexal masses or tenderness will be elicited. A fixed uterus, nodular or tender uterosacral ligaments and enlarged tender ovaries are highly suggestive of endometriosis. Features of endometriosis is more readily elicited during the menses but the patient must be counselled and agree to be examined then. A digital rectal examination will be done if indicated
b) Blood for full blood count and C-Reactive protein (CRP) will be done. An elevated whitecell count is indicative of an acute infection and an elevated CRP indicates an inflammatory process. Neither will be helpful in identifying the cause of chronic pelvic pain.
If there are urinary symptoms, a mid stream specimen of urine will be sent for microscopy, and culture.If this is negative in the presence of bladder pain cystoscopy and possible biopsy may be indicated.
A pelvic ultrasound to evaluate the uterus and adnexae is helpful.An enlarged uterus and features of adenomyosis may be seen. Enlarged ovaries with endometriotic cysts will also be identified, but endometriotic deposits and adhesions would not be seen.
Laparoscopy is the gold standard investigation for chronic pelvic pain.It will detect adhesions, ovarian masses and some cases of endometriosis. It may not be useful to diagnose deeply infiltrating endometriosis, adenomyosis,or bladder and gastrointestinal disease. General anaesthesia is required and in addition to anaesthetic complications there is a small risk of injury to blader, bowel and blood vessels.
MRI does not offer any advantage over laparoscopy, is expensive and not readily available at all hospitals.

c)Treatment options for moderate andometriosis include medical and surgical.
Non-steroidal anti-inflammatory drugs (NSAIDS), in particular naproxen, have not been found te be effective.
Hormonal drugs are all equally effective, but limited by threir side effect profile. They may not totally suppress pain and are not suitable if she wishes to conceive.
The COCP is cheap and is suitable if the patient does not wish to conceive.
Progestogens may cause weight gain, mood changes, acne and bloating. Pprolonged use may cause decreased bone mineral density (BMD). Unpredictable breakthrough bleeding may occur.
Danazol can produce marked androgenic side-effects including deepening of the voice and breast atrophy which may be irreversible. BMD increases.
Gestrinone less severe androgenic side effects than danazol.
GnRH agonists produces menopausal side effects as well as reduction in BMD of approximately 6% at six months of use. This may not be totally reversible. Add-Back therapy with combined hormone replacement therapy or tibolone has been shown to reduce this as well as alleviate vasomotor symptoms. GnRH can be used for a longer period if Add Back therapy is used.
Surgical treatment provide varying degrees of pain relief. The use of pre-operative or post-operative hormonal treatment to improve pain relief after surgery is not recommended.
Laparoscopic ablation of endometriotic deposits provide pain relief which persists in about 60% of patients after six months. Laparoscopic excision provides better results at six months but similar results to ablation at 12 months. It is associated with more complications and surgery lasts longer. Excision of endometriotic cysts results in effective pain relief, improves pregnancy outcome if this is desired and provides tissue to confirm the diagnosis and exclude malignancy.
Laparoscopic uterine nerve ablation (LUNA) does not provide effective pain relief and is assciated with uterine prolapse and bladder dysfunction. Presacral neurectomy provides better pain relief than LUNA but is associated with more complications.
The definitive treatment is bilateral oophorectomy but this will not be done for moderate endometriosis in a young woman.
dadad Posted by PAUL A.

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