Essay 281 - Endometriosis

A healthy 30 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during sexual intercourse. Her symptoms have not responded to simple analgesia. (a) Discuss your assessment [10 marks]. (b) She is found to have moderately severe endometriosis. Discuss the available treatment options [10 marks]

A)

Ask her parity and future reproductive ambition. Ask about her desire for contraception and assess her attitude toward hormonal contraception and amenorrhea. Ask her menstrual history noting her menarche, LMP, cycle length and regularity. Ask about a prior history of pelvic inflammatory disease (PID). Ask about the effect on her quality of life and assess this by asking her to fill and appropriate questionaire. Ask about aggravating factors like menstruation which suggests a gynaecological cause. Ask about associated gastro-intestinal(GI) symptoms like constipation and dychezia which suggests a GI cause. Ask about urological symptoms like dysuria, haematuria and suprapubic pain relieved by urination which suggests a urological cause. Ask about prior pelvic injury and pain with movement as this suggests a musculoskeletal cause. Ask sensitively about prior sexual abuse or depressive illness as this indicates a pyschological component. Ask about prior abdominal or pelvic surgery as adhesions may contribute to her pain. Ask about prior treatment options attemprted such as prior laparoscopic adhesiolysis. On examination, palpate her abdomen for abdominal/pelvic masses, tenderness, rebound tenderness and gaurding. Perform a vaginal exam for cervical excitation tenderness and pelvic masses. Palpate vaginal endometriotic nodules and nodules in the recto-vaginal septum. Perform a speculum exam looking for vaginal endometrial deposists and a rectal exam for endometrial deposits.Note that endometrial deposists may be more prominent during menstruation and examination may be performed at this time if the woman is willing. Regarding investigations, perform a full blood count ( FBC) looking for a leucocytosis which may indicate infection(PID). Perform a C-reactive protein (CRP) which may be raised in infection(PID). Perform a urethral. endocervical and high vaginal swab for chlamydia culture, ELISA or PCR. Note that a positive or negative result does not diagnose or refute PID. Perform a pelvic ultrasound scan looking for pelvic masses like fibroids or ovarian masses. A normal result may be reassuring to the woman. Recognise that an ultrasound scan may not detect adenomyosis or endometriosis. Perform a mid-stream urine for culture and perform a dipstick test for leucocytes, haematuria and protein which would suggest a UTI. Perform an MRI of the pelvis as a non-invasive way of viewing endometriotic deposits. Perform a laparoscopic pelvic examination to diagnose endometriosis, pelvic masses like ovarian and fibroid masses and adhesisons which is suggestive of PID. Recognise the potential morbidity associated with laparoscopy and that recto-vaginal endometriotic deposits, adenomyosis and IBS are not diagnosed at laparoscopy. Perform a cystoscopy if urinary symptoms to diagnose interstitial cystitis.

B)

Expectant mangement avoids the side effects of medical options and surgical morbidity. However this may be unacceptable to the patient. Medical options include the Combined Oral Contraceptive Pill, Progestogens, GnRH analogues, Danozol and Gestrinone. These agents are equally effective in relieving endometriosis associated pain but differ in their side effect profiles which limit their use. The COCP may be used cyclically, tricyclicaly or continuously with best pain relief resulting from a continuous regime. Contraception may be a beneficial effect if desired. Explain that side effects include nausea, breast tenderness and bloatiness. Ensure no contraindications such as migraines with aura and Thrombo-embolic disease. High dose oral progestogens are effective when amenorrhea induced. Depot progestogens are also effective with easire compliance. Explain that side effects include irregular bleeding, acne and weight gain. Explain that deopt progestogens provide reliable contraception but long term use predisposes to osteopenia. Use of GnRH analogues maybe limitted by their side effects which include climacteric symptoms( hot flushes, vaginal dryness). Use for more than 6months is associated with 6% bone mineral loss and predispositon to osteoporosis with long term use. This risk is minimised with add back therapy (tibolone) when use upto 2 years. The androgenic side effects of danozol make it a less attractive option. These include abnormal hair growth, breast atrophy(temporary) and a deepened voice(permanent). Danozol is not contraceptive and barrier contraceptive is advised. Explain that if pregnancy occurs with Danozol a female fetus may be virilised. Gestrinone has similar mode of action and efficacy to Danozol but less androgenic side effects. Surgical options include laparoscopic excision or ablation of endometriotic deposists which have good efficacy in relieving endometriosis assocaited pain. Disadvantages of laparoscopy include entry related injury (to Bladder, Bowel and vascular injury), post operative shoulder pain and portsite complications( hernia, endometriotic deposits).Laparoscopy will miss Recto-vaginal septum deposits  which may be better dealt with by a colo-rectal surgeon.Laparoscopic Uterine Nerve ablation is ineffective and not recommended.

a.

I will take a history asking about severity of each of her symptoms, whether her pelvic pain is cyclical, localised to particular side of pelvis and whether it radiates to thighs, as this would suggest endometriosis. I will also ask about the impact of her symptoms on her quality of life.I will ask about the presence of loose stools and constipation alternating at frequent intervals, as this would suggest possible IBS.I will ask about her menstrual history including menarche, length and regularity of her cycles and duration and heaviness of bleeds. I will ask about her sexual history, change of sexual partners, past or current history of STI’s,eg Chlamydia, unprotected sexual intercourse and the presence of abnormal vaginal discharge and IMB, to assess the likelihood of  PID. I will ask about her past and present contraceptive use, compliance and LMP,to assess the likelihood of current pregnancy, as this will significantly affect her options of treatment. I will ask about specific treatments tried and the response to them.

I will ask about a family history of ovarian cancer syndromes eg BRCA1 and BRCA2. I will ask about weight loss, easy satiety, abdominal bloating and frequency and urgency of micturition, as this may suggest possibility of ovarian malignancy.

I will ask about her obstetric history, any pregnancies and outcome, mode of delivery and complications. I will enquire about the time of her last birth, and check for breastfeeding as this may influence her choice of treatments, and help to assess the likelihood of adenomyosis.

I will ask about past history of pelvic and or abdominal surgery, to assess the likelihood of adhesions as the cause of pain but also the technical difficulty of possible laparoscopy.

I will ask about her fertility intentions and her current need for contraception as these can influence the available range of medical and surgical treatment options.

I will ask about her smear history including her last smear, and offer her one if due.

I will examine her, checking her weight height and BMI, abdominal examination for scars, masses and tenderness, speculum examination looking for abnormal vaginal discharge and vaginal endometriosis. I will carry out a bimanual examination for adnexal masses and tenderness, uterine size and and outline, position and mobility, and cervical motion tenderness. A fixed retroverted uterus with uterosacral nodularity may suggest endometriosis, while a adnexal tenderness and cervical motion tenderness will suggest PID.An enlarged globular tender uterus will suggest adenomyosis particularly in a parous woman.

I will arrange a urine pregnancy test to exclude pregnancy.

I will arrange a full blood count, CRP and ESR to assess for anemia, elevated markers of infection such as WBC, CRP and ESR if her history suggests PID. I will take endocervical, high vaginal and urethral swabs for microscopy, culture and sensitivity for Chlamydia, gonorrhoea and other STI’s, if she has a high risk history or clinical findings of PID.I will arrange for early morning clean catch urine sample for NAAT for Chlamydia and gonorrhoea as this improves detection.

I will arrange a pelvic ultrasound, usually TVS, to exclude ovarian cysts and endometriomas, pelvic abscess and tubovarian masses.

If deeply infilterating endometriosis is suspected I will arrange MRI pelvis which may be helpful in diagnosis.

If a trial of conservative treatment is declined or unacceptable I will arrange a diagnostic laparoscopy, which is the gold standard diagnostic tool for many pelvic pathologies eg endometriosis, adhesions, and PID.

b.I will see her in the context of a pelvic pain clinic, with a gynaecologist with interest in pelvic pain and endometriosis, a specialist nurse, a counsellor and a pain management specialist or anaesthetist.

I will explain her diagnosis to her, and explain that there is poor correlation between the extent of endometriosis and pain. If her symptoms are mild she may opt for no intervention. If she requires treatment, while not trying to conceive, she may be offered COCP eg yasmin after excluding contraindications. This reduces endometriosis through ovulation suppression, offers effective contraception and reduces HMB.

She may also be offered the miraena IUS, which reduces pelvic pain, HMB, dysmenorrhoea, endometriosis related pain and offers effective contraception.There is a risk of unscheduled bleeding, particularly in the first six months.there may be a side effect of acne, breast discomfort, and oily skin.

She may be offered the injectable progestogen. This reduces endometriosis pain by ovulation suppression. It offers effective contraception, and eg DMPA has to be injected every 12 weeks. It has a risk of abnormal bleeding pattern, weight gain, and loss of bone mineral density if used for more than 2years. Return to fertility may be delayed by up to a year upon discontinuation.

Implannon is a long term progestogen alternative. It is an implant that is effective for three years. It causes ovulation suppression, thereby reducing endometriosis. It avoids the risks of loss of Bone mineral density and delay in return to fertility, but carries a risk of unscheduled bleeding. It may cause amenorrhoea.

GnRh analogues may be offered. This is highly effective treatment for endometriosis related pain. It’s use is limited by the loss of bone mineral density if used beyond six months. It is accompanied by menopausal symptoms of hot flushes, mood swings and loss of libido, and estrogen, progestogen and androgen replacement or tibolone should be offered.

Surgical options of treatment may be considered following failed medical treatment and this may involve laparocopic excision or ablation of endometriosis, cystectomy for endometriomas and adhesiolysis. In extensive disease, referral to an advanced laparoscopic surgeons may be required where extensive resection of deeply infilterating endometriosis, resection of affected bowel with temporary colostomies for later reversal may be required. In women who have completed their families TAH/BSO may be offered with long term HRT till age 51. Some of these Difficult procedures may have to be done by laparotomy.

Where pain persists in spite of these measures, she should be seen by the pain management specialist.

She will receive adequate counselling psychological support throughout her care, with referral for occupational health advise if neccessary. I will provide written information about endometriosis and introduce her to an endometriosis support group, eg www.endometriosis.org/support.

A healthy 30 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during sexual intercourse. Her symptoms have not responded to simple analgesia. (a) Discuss your assessment [10 marks].

I will need to check  whether she has any children, as endometriosis may be associated with subfertility, whether she has completed her family size as this will have implications on therapeutic choices, the nature of pain should be checked whether related to menstrual cycle or not, as noncyclic pain is associated with presence of adhesions or endometriosis and is aggravated by movement. Bowel symptoms e.g. (constipation, bloating) may point to irritable bowel syndrome, or possibility of ovarian tumour, and urinary symptoms like frequency, urgency, hematuria may point to interstitial cystitis. History of pelvic infections and past surgeries should be checked as these may cause adhesions and pain. The effect of this pain on her quality of life should be assessed by a questionnaire as this will reflect the severity of the condition and will help in assessing her response after treatment.

Abdominal exam will reveal if there is palpable masses, tenderness, a bimanual exam will check for uterine size, position and tenderness as a tender fixed, retroverted uterus is associated with edometriosis. Also tenderness and nodularities may be felt over the uterosacral ligaments and this is best elicited during menses. This will point to deep nodular endometriosis. Palpable adnexal masses are suggestive of endometriomas. A rectal exam may be needed if patient reported rectal bleeding.

Transvaginal ultrasound will help detect ovarian endometriomas and has no value in detecting peritoneal disease. MRI may be used  to detect deep nodular endometriosis or adenomyosis. Blood test including FBC and CRP may detect an inflammatory process. Urine culture is requested to check for infection. Urethrat swab PCS is done to test for chlamydia, but if negative does not excluded PID. Serum CA125 is a tumour marker that may be increased in endometriosis, but is non specific.

cystoscopy may be requested to check for interstitial cystitis and will show hemorrhagic areas upon distending the bladder.It may also detect endometriosis invading the bladder mucosa. Intravenous pyelography and barium enema may also be needed to assess for deep infiltrating endometriosis to assess ureters and bowels.

Laparoscopy is the gold standard method to diagnose endometriosis. It also may rule out pelvic pathologies like ovarian tumours, adhesions. It has a 3% risk of minor complications like pain,infection and 06-1.8/1000 risk of bowel, bladder and blood vessel injury.

 (b) She is found to have moderately severe endometriosis. Discuss the available treatment options [10 marks]

the available treatment options include complementary therapy e.g TENS, acupuncture, use of vitamin E. there are no evidence to recommend their use, but should not be denied if the patient asks for them, and can be used in conjunction with other treatments. Medical treatment will include non hormonal  e.g NSAID, paracetamol, codeine which has been already tried in this patient and failed, the other option is hormonal using COCP in either cyclic or continuous pattern. Progesterone can be given continuously in order to produce amenorrhea . Other forms of progesterone include Mirena IUS which has been found to be effective in reducing endometriosis caused pain and this was sustained up to 3years of use.Danazol is an androgenic anti estrogen anti progesterone,  that is used for treatment of endometriosis. It causes virilising side effects and proper contraception should be used to prevent virilising effect on the fetus. It also causes weight gain. Gestrinone is an androgenic anti-progestin licenced for use in treament of pain due to endometriosis at a dose of 2.5mg twice weekly.  Side effects include virilising symptoms (less severe than danazol )weight gain and should be used with appropriate contraception. Depot medroxyprogesterone acetate( depot provera) is an injectable progesterone that can be used for up to 2 years as longer duration of use may be associated with osteoporosis. It also causes irregular bleeding pattern and weight gain. GnRH agonist can be used to down regulate the GnRH receptors and abolish ovulation. the treatment causes a hypoestrogenic state leading to menopausal symptoms and osteoporosis(loss of 6% BMD). That's why treatment should be limited to 6 months and an add back estrogen or tibolone used to prevent osteoporosis and alleviate symptoms. The treatment is effective in abolishing pain but recurrence will occur 6 12 months after therapy is stopped.

Surgical treatment includes conservative surgery in which ablation of all visible endometriotic lesions is performed, and restoring anatomy as possible, as well as adhesiolysis. This can be done laparoscopically or through laparotomy. Deep infiltrating nodular lesions should be excised completely. If endometriomas are larger than 4 cm they should be excised and their cyst wall removed as this will help reduce recurrence. This might affect the ovarian reserve, but is beneficial if the event of subsequent IVF, as this will improve access to ovarian follicles and reduce incidence of infection or abscess formation. If invasive disease is suspected, referral to a center with expertise in managing these cases should be done. Preop bowel prep and involvement of a multidisciplinary team including colorectal surgeon, urologist may be needed for excisions of affected bowel portion or bladder/ ureter. A colostomy may be needed.

Radical surgery in which with hysterectomy and bilateral oopherectomy as well as excision of all endometriotic lesions is used as a last resort in severe debilitating cases where failure of previous surgical treatment, or recurrence of severe symptoms. GnRHagonist should be tried before surgery to check whether oopherectomy will help in abolishing the patient symptoms.  Decision for HRT using estrogen or combined estrogen with progesterone should be individualised.

Laporoscopic uterine nerve ablation LUNA has not been shown to improve pain in patient with endometriosis. Presacral neurectomy may be tried in severe pain due to endometriosis but has risks on subsequent constipation, pelvic organ prolapse and bladder dysfunction.

I would ask the patient about the pain severity, how it affects her quality of life, its relation to her posture, because there may be musculoskeletal causes. I would ask her about her fertility wishes, if she need contraceptive or not. I would ask her about bowl symptoms like bloating, diarrhea, and constipation, according to Rome criteria for diagnosing irritable bowel syndrome (IBS), and about any red flag symptoms which need referral of patient, although firm diagnosis of IBS cannot be made by history alone. I would ask her about Obstetrical and gynaecological history, if she has previous pregnancy the mode of delivery, because caesarean section, and any surgery can cause adhesions. Sensitively I would ask the patient about sexual history if she is active and ask about history of sexually transmitted illnesses which can lead to pelvic inflammatory disease (PID). Also I would enquire about her social life if there is any stress, and sexual or physical  abuse because psychological causes can cause chronic pelvic pain.

I will do abdominal examination to look for masses, distention, tenderness, guardening. Also I will look for any pelvic organ prolapse and any perineal ulcer which can resuls from inflammatory bowl diseases (IBD). pelvic examination is important if sexually active to see the uterus, fixed or mobile, anteverted or retroverted any nodularity all can be features of endometriosis. Adenxal masses or cervical excitation can be known also.

In investigations i will do FBC to see if leucocytosis or not, and inflammatory markers like CRP, ESR all can be raised in infections. I will screen for Chlamydia trachomatis and gonorrhea if sexually active, although if positive it is not diagnostic, but it can support the diagnosis, and if negative it is will not exclude the diagnosis. Other STIs investigations can be offered. Non invasive investigations like Ultra sound scanning can be done, which can find any adenxal mass or endometrioma, but it cannot diagnoses endometriosis or IBS, IBD, It can reassure the patient. MRI can be done to diagnose the adenomyosis, it can miss minimal endometriosis, It is less costly than laparoscopy. Laparoscopy is second line investigation it is better to be done after 6 month of hormonal treatment. It carries the risk of tissue injuries and complications of anaesthesia. It can overestimate the minimal endometriosis.  CA125 can be done which raised in endiometriosis and invasive diseases.

Regarding treatment, I will start with hormonal drugs  because the patient already took simple analgesic. Hormonal treatment is effective, but symptoms recur if treatment stopped. COCP can be given cyclically or continuously after excluding any contraindications like migraine or smoking. It is suitable if contraceptive is needed. Progestogen in Large doses can be given but it can causes amenorrhea, irregular bleeding, acne, bloating and breast tenderness. GnRh analoges can be given but it causes climactric symptom and osteoporosis, so add back therapy is needed. it is costly and given by intranasal or injections. danazol is an option but it is androgenic and causes acne deepen the voice, and it is not contraceptive so barriers contraceptives should be used so as not to virilize the fetus if pregnancy occur. Gestrinone effect like danazole but carries less androgenic side effects. Laparoscopic ablations can be done after empirical hormonal treatment and it is useful for patient with history of infertility, but it carries the risks  of laparoscopy and anaesthesesia like haemorrhage and tissue injuries. Patient may be counseled that pain may not be improved. Some women about 30%  has improvement after laparoscopy. Other treatment can be tried for pain, like TENS, and alternatives medicine like acupuncture. LUNA has no effect as treatment.               

The woman should be enquired in a sensitive manner if her symptoms are severe enough to have an impact on her quality of life.She should be asked to describe the exact nature of her pain ,any diurnal variation,aggravating and relieving factors.If vomiting was present it implies severity of pain.A detailed menstrual history to be asked for the cycle regularity,lengtAh,amount of flow.Whether her pain aggravated prior to or at the start of cycle should be noted.The type of analgesic she used ,frequency and the dose has to be asked.History of any discharge per vaginum associated with foul smell ,itching could suggest a pelvic inflammatory disease.If so any treatment given for the same must be asked.Her parity and past history of any miscarriages to be asked for. A comprehensive sexual history must be asked from the woman preferably in privacy.The exact nature of pain during intercourse to be asked as pain with deep penetration points to deeply infiltrating endometriosis,while a superficial pain can occur with local vulvar inflammation or pelvic infections.Any disharmony with her partner or a change of partner to be asked in a sensitive manner to rule out a underlying  psychosexual cause .A history of dysuria,burning micturition,frequency would point to a chronic cystitis.Pain during defaecation can occur with endometriosis but a history of bleeding per rectum may warrant a prompt referral to a gastroenterologist to rule out a malignancy.The woman’s most bothering symptom for which she is seeking treatment and,her future fertility wishes must be explored as it may modify treatment decisions.An abdominal examination to be done to look for any abdominopelvic mass,tenderness, free fluid.Per speculum to be done to look for any discharge,if present swabs to be taken for culture sensitivity.Per vaginal exam to look for uterine size,fixity,adnexal masses,tenderness,nodulrity in pouch of douglas.A per rectal exam  is essential if bleeding p/R or suspected mass after explaining to her.  
        A Full blood count and CRP to be done as leucocytosis and raised CRP point to infective cause. A urine routine and microscopy to look for pus cells is to be done.An abdominal and a transvaginal Ultrasound will pick up pelvic mass and endometriomas.More importantly, a normal report will really reassure the woman.CA-125 is useful if there is an ovarian mass,while in endometriosis it is marginally raised and such women benefit with  laparoscopy.Laparoscopy is the gold standard in arriving at a diagnosis as analgesics have not worked in her. Also with consent it can be made operative laparoscopy with an intent to treat. MRI is only an adjunct to laparoscopy in deep endometriosis. IVP and barium enema done if suspected urological or GI cause.Again a negative laparoscopy could be ressuring that there is no sinister pathology.Woman should be involved in decision making and information leaflets must be given.
            If she has moderate to severe endometriosis,treatment must be offered in specialised units. As pain is her main symptom,with informed consent on operative laparoscopy for adesiolysis,removal of visible implants as much as possible can be done.Cystectomy preferred over drainage or ablation for all endometriomas >4cm in size and should be sent for histopathology to rule out any malignancy. Surgery is definitely better than medical management alone in severe endometriosis with pain, but with deep seated lesions on bowel or bladder, there is a risk of injury to the viscera ,should  be explained prior to surgery.Surgeries like LUNA (laparoscopic uterine nerve ablation) and Presacral Neurectomy are associated with complications and are best avoided. If the woman refuses surgery and has no plans of immediate pregnancy combined OCPs are an option cyclical or continuous,but she must be advised not to postpone her pregnancy as subfertility is an issue with severe endometriosis.Danazol and Gestrinone are not preferred as they are androgenic. Hepatotoxicity is another problem with Danazol. With Danazol or GnRH analogues pain recurs as early as 6 months after stoppage of treatment and disease recurrence at 5 years is as high as 70%.  Also, Medical management after surgery has no added advantage except LNG-IUS which offers some pain relief but cannot be used if desires fertility.

With regards to fertility, IVF is the preferred option for moderate to severe endometriosis with severe adhesions and distorted tubal anatomy and there is no role for just ovarian hyperstimulation in such  cases . Treatment with GnRH analogues 3 to 6 cycles prior to IVF has shown to improve success rates. Removal of endometriomas >4 cm also helps . Success rates for age are slightly lesser in women with endometriosis. Intrauterine insemination would help in mild or minimal endometriosis but not in severe disease and would only waste time and increase couples anxiety. Couple should be involved in decision making .Information Leaflets and contact details of support groups like www.endometriosissociety.org must be provided.

A] Take detail history of the painful periods and pelvic pain and its effect on quality of life. menstrual history such as LMP, regularity , duration of flow , amount of flow and associated dysmenorrhoea .obstretic history such as number of  children and mode of delivery and fertility wishes . history of previous contraception used and presently using and any complications associated with it. any contraindication to hormonal contraception  . history of any previous abdominal and pelvic surgeries and any cesaerean sections  for intra abdominal adhesions . take sexual history and the associated complications . medical history of using any treatment for chronic diseases , maigran, any use of enzyme inducing drugs . any history of previous treatment and what was the out come .history of number of sexual partners any recent change of partnerand use of condom during sexual intercourse for sexually transmitted infection . take history to rule out non gynaecological cause of pelvic pain such as  history of bloating, alternate diarrhoea and constipation for irritable bowel symptoms . any history of weight loss ,loss of appetite ,early satiety and rectal bleeding to rule out malignancy but however malignancy is uncommon in this age group .any history of sexual abuse before . general examination  such as Temperature, pulse, BP BMI . abdominal examination for any tenderness, rebound tenderness , any palpable masses . vaginal examination may not detect any pathology , palpate the size of the uterus any tuboovarian mass , CET and palpable nodules on uterosacral ligaments and POD .Investigations such as blood for LFT, FBC, RFT . endocervical  , urethral and rectal swabs for STI . early morning urine sample for PCR  to detect clamydia  .TVS  for any ovarian mass and abdominal and pelvic pathology , this may reassure the patient and detect pathology not identified on vaginal examination . CA 125 may be elevated  but no evidence that it is only due to endometriosis . MRI to detect adenomyosis and other pathologies  and endometrial deposits . The gold standard investigation is diagnostic laproscopy ,councel the patient before hand that no cause may be identified in some . endometial deposits can be seen and simultaneously endometrial ablation can be done . risk of surgical exposure  ,bowel , bladder injuries, and injuries to the great vessels .laparoscopy is not only diagnostic but also curative in some patients.

B]  THis requires MDT approach involving gynaecologist, pain clinic , gp. There is medical and surgical management . suppression of ovarian function  reduces endometriosis associated pain but recurrance is common after stopping the treatment. hormonal treatment in the form of combined oral hormonal contraception can be given this not only improves her symptoms such as dysmenorrhoea  but also acts as effective contraception but side effects such as nausea ,vomiting and DVT . LNG ius can be used , this decreases her dysmenorrhoea , dysperunia and also act as effective contraception . but irregular bleeding is seen in first few months and amennorhoea in  patients which may not be accepted by the patient .side effects of progesterone such as bloating , headache, breast tenderness may be unacceptable . GNRH analogue for about six months . the treatment is costly . this suppresses the ovarian activity  but cannot be used for more than six months since  it decreases the  bone mineral density  by 6 %, however this can be protected by add back therapy in the form of low dose estrogen and progesterone or tibolone  . there is  no certainity about the duration of use but can be used upto 2 yrs  .Danazol can be used for upto six months but it has androgenic side effects . medroxy progesterone acetate can be used  this not only relives the symptoms but also act as effective contraception ,but this has progesterogenic side effects which is not accepted by some patients.gestrinone can be used but associated side effects limit its use. surgical treatment such as laproscopic endometrial ablation . this relives symptoms associated with endometriosis but it some patients it does not benefit if disease is due to other cause , incomplete excision, or disease recurrance .  risk of surgical exposure , bowel, bladder damage . adhesiolysis can be done in case of intra abdominal adhesion but no evidence  that it relives pain .  LUNA dose not reduce endometriosis associated pain . presacral neurectomy can be done but not helpful .If the patient has completed her family and has severe symptoms she can have TAH and BSO but she will have premature menopause and needs HRT until age of menopause . psychological councelling in case of psychosexual abuse . complementary therapies such as reflexology, acupuncture may be benefitted . provide information leaflet and self help support group .    

A) Adequate time should be allowed for initial assessment and her therory of the cause of the pain should be disussed.Detalied history about pattern of pain,and relation to the menstrural cycle should be asked.also,if associated or increased by movemnts.i will request from the women to complete  daily pain diary fo 2 to 3 cycles to know provoking fator of the pain.iwill ask about bowel symptoms such as changing in the frequency or the form of the stool.if pain relieved after defetion as it refere to irritable bowel syndrome.asking about urinary symotoms such as urgency,frequency dysuia, can refer to infection .i would  ask about peristent bloating,changing in the appetite or loss of wight recently as it may refer to ovarian carcinoma.i would senstively ask about past or present sexual assult.moreover i would ask about effect of this pain on her quality of life.if associated with lack of sleep.i would ask if the pain make her to be absent from her work.

future pregnancy wishes should be asked as it affects the tratment option.

i will perform abdominal examination looking for focal tenderness also to check any abdominal mass

vaginal speculum  to look for any vaginal discharge and if present endocervical swab  should be taken.for diagnosing of chlamydia or gonorrhea.although if swab is negative PID can not be ruled out.

vaginal examination to  detect uterine size ,mobility and detetion of any adenxal mass.per rectal examinationif there is history of rectal bleeding to detect nodules in the douglas pouch. which refer to endometriosis.and it better to be examined during menstruation.

i will request FBC ,and CRP as if leucocytosis and raised CRP  refer to infection.

i will request transvaginal u/s to check any ovarian cyst,adenxel mass.MRI can be used if there is suscpetion of endometriosis or adenomyosis.Diagnostic laproscopy better to be  performed after theraputic hormonal trial for 3-6 monthes and possibility of negative finding should be discussed with the woman..

B)If the pain is the main concern of the women. iwould  start by medical treatment .coc pills can be tried first as she had no resonse to simple analgesia.coc can be taken conventially and better to be taken  tricycling.also pogestogin also effectine if taken by sufficient dose to induce ammenorrhea .side effects include mood changing.breast pain .acne and prolonged use carry risk of decrease bone mineral density.danazole is ant estrogen antiprogesterone  can effectively reduce pain but  has androgenic side effect such as hirsutism,acne.breast atrophy. gesternon can also be used twice weekly but it also associated with androgenic side eddfect but kess than danazole.Barrier contraception should be used if gestrinon or danzole are used.

GnRH analouge effectively inhibit ovulation and reduce pain but it carry risk of derease bone mineral density if used more than 6 monthes.tibolone can be used as add back therapy to extend use of GnRH up to 2 years.

The women should be counselled that no drug is effective more than other drug.but her choice will be as regard side effect of each drug.she should be also councelled that pain relief is not alwayes complete.

Another option is use of leveonorgeteral IUD can effectively decrease pain.finally surgical treatment an be tried .laproscopical ablation of endometriosis and cutting of adhesion associated with improvemnt of the pain.Laproscopic uterinenerve ablation is not effective in pain relief.If fertility is not desired and the patient complete her family.pelvic clearnce can be tried if medical and surgical methoda are all failed.written information about the treatment option should be given to the women and offer her support group such as national endometriosis society.

I will check history asking about nature of pain cyclic or not. Associated bowel symptoms (alternative diarrhea with conistipation,abdominal pain improved by defecation may point to irritable bowel syndrome) also cyclic dyschasia if endometriosis. I will ask about urinary symptoms as it may point to interstitial cyctitis. I will ask about sexual history to check risk factors of chronic pelvic inflammatory disease PID e.g. multiple sexual partners, recent change of partner & history of previous episodes of PID. Also obstetric history including infertility points to endometriosis,I will ask about future plan for pregnancy, previous repeated CS may cause dense vascular adhesion.

Examination to detect abdominal tenderness or masses. P/V to detect fixed RVF uterus, tender uterosacral ligament & deeply infilterating nodules in dougls pouch are suggestive of endometriosis. Tender cervical motion may point to chronic PID or endometriosis. P/S examination may reveale endometriotic leasion in cervix or vagina or signs of chronic cervicitis (hypertrophy & purulent discharge).

Invastigation including transabdominal & vaginal ultrasound to detect adnexal mass e.g. ovarian endometrioma, or adenomisois. However it is poor in detecting peritoneal endometriosis or PID.

Laparoscopy has the advantage of panoramic view of pelvis, detect both ovarian & peritoneal endometriosis, dense vascular adhesion, allow intake of swap for culture & sensitivity if infection suspected.However it cannot detect adenomiosis & it is negative in one third of cases of chronic pelvic pain.

Ca 125 is not hepful in diagnosis of chronic pelvic pain as it is non specific & raised in many conditios. However it can be used to calculate risk of malignancy index in case of ovarian mass.

b) Treatment options:

Treatment should be individualized, addressing womans need (pain symptoms or infertility problems). I will explain nature of disease, give her written information allow woman to choose between options.

 Options for pain symptoms include hormonal treatment to suppress ovaries using combined oral contraception either conventionally or tricyclic, progestogen ( depo provera) ,gestrinon, dannazol,aromatase inhibitors (letrizole) & GNRH analogue.

All are equally effective but differ in their side effects profile which may limit duration of treatment.Oral contraception & depoprovera can be used long tim.Dannazol has androgenic side effects (acne, oily skin , weight gain, muscle tenderness, hirsutism & irreversible deepening of voice).Gestrinon has less androgenic side effects than dannazole. GnRH analogue causes 6% bone mineral density loss if used >6 months & menopausal symptoms (hot flushes,dry vagina).Its use can be prolonged up to 2 years by adding HRT estrogen & progesterone to reduce symptoms &keep bone density. Disadvantages of hormonal treatment are side effects, incomplete pain relief & some cases may fail to respond at all.

Non steroidal anti-inflammatory drugs e.g. naproxen: insufficient evidence to recommend them for pain relief of endometriosis as many cases found it ineffective.

Levonorgestril intrauterine system (Mirena) has been proved to be effective in relieving pain as high local level of progestagen help to regress leasions.

The role of complementary medicine (herbal, reflexology,TENS) is unclear, however it can not be excluded if patient already using them & found them helpful.

LUNA (laparoscopic uterine nerve ablation) : is not effective & not recommended, presacral neurectomy is more effective but more complex with increased morbidity.

Radical surgery total abdominal hysterectomy with bilateral salpingo oophorectomy is an option but not suitable regarding young age of woman &serious health hazards.

Treatment option for infertility including IFV is recommended in view of severe form of disease, Laparoscopic excision of endometrioma >4cm is indicated before IVF.

Laparoscopic ablation & adhesiolysis  have uncertain role in improving fertility in severe endometriosis.

Hormonal treatment doesn’t improve fertility with loss of chance of pregnancy & is not recommended.

IUI has poor results in severe disease & is not recommended       

The woman should be enquired in a sensitive manner if her symptoms are severe enough to have an impact on her quality of life (1).She should be asked to describe the exact nature of her pain ,any diurnal variation,aggravating and relieving factors.If vomiting was present it implies severity of pain ? meaning???.A detailed menstrual history to be asked for the cycle regularity,lengtAh,amount of flow.Whether her pain aggravated prior to or at the start of cycle should be noted why??.The type of analgesic she used ,frequency and the dose has to be asked.History of any discharge per vaginum associated with foul smell ,itching could suggest a pelvic inflammatory disease.If so any treatment given for the same must be asked.Her parity and past history of any miscarriages to be asked for why is miscarriage relevant?. A comprehensive sexual history must be asked from the woman preferably in privacy will you take the rest of the history in public??.The exact nature of pain during intercourse to be asked as pain with deep penetration points to deeply infiltrating endometriosis no, does not tell you that endometriosis is deeply infiltrating,while a superficial pain can occur with local vulvar inflammation or pelvic infections no – you do not get superficial dyspareunia with pelvic infection.Any disharmony ?? defined as??? with her partner or a change of partner to be asked in a sensitive manner to rule out a underlying  psychosexual cause .A history of dysuria,burning micturition,frequency would point to a chronic cystitis points to UTI .Pain during defaecation can occur with endometriosis but a history of bleeding per rectum may warrant a prompt referral to a gastroenterologist to rule out a malignancy in a 30 year old??.The woman’s most bothering symptom for which she is seeking treatment and,her future fertility wishes must be explored as it may modify treatment decisions (1).An abdominal examination to be done to look for any abdominopelvic mass,tenderness (1), free fluid.Per speculum to be done to look for any discharge,if present swabs to be taken for culture sensitivity.Per vaginal exam to look for uterine size,fixity,adnexal masses,tenderness,nodulrity in pouch of douglas (1).A per rectal exam  is essential if bleeding p/R or suspected mass after explaining to her.  â€¨        A Full blood count and CRP to be done as leucocytosis and raised CRP point to infective cause. A urine routine and microscopy to look for pus cells is to be done.An abdominal and a transvaginal Ultrasound will pick up pelvic mass and endometriomas (1).More importantly, a normal report will really reassure the woman.CA-125 is useful if there is an ovarian mass,while in endometriosis it is marginally raised and such women benefit with  laparoscopy (1).Laparoscopy is the gold standard (1) in arriving at a diagnosis as analgesics have not worked in her. Also with consent it can be made operative laparoscopy with an intent to treat. MRI is only an adjunct to laparoscopy in deep endometriosis. IVP and barium enema done if suspected urological or GI cause.Again a negative laparoscopy could be ressuring that there is no sinister pathology.Woman should be involved in decision making and information leaflets must be given.
            If she has moderate to severe endometriosis,treatment must be offered in specialised units. As pain is her main symptom,with informed consent on operative laparoscopy for adesiolysis,removal of visible implants as much as possible can be done (1).Cystectomy preferred over drainage or ablation for all endometriomas >4cm in size and should be sent for histopathology to rule out any malignancy. Surgery is definitely better than medical management alone in severe endometriosis with pain ? evidence?? Is there a correlation between severity of endometriosis and severity of pain?, but with deep seated lesions on bowel or bladder, there is a risk of injury to the viscera ,should  be explained prior to surgery.Surgeries like LUNA (laparoscopic uterine nerve ablation) and Presacral Neurectomy are associated with complications are other operations not associated with complications? and are best avoided. If the woman refuses surgery and has no plans of immediate pregnancy combined OCPs are an option cyclical or continuous (1),but she must be advised not to postpone her pregnancy as subfertility is an issue with severe endometriosis.Danazol and Gestrinone are not preferred as they are androgenic. Hepatotoxicity is another problem with Danazol. With Danazol or GnRH analogues pain recurs as early as 6 months after stoppage of treatment and disease recurrence at 5 years is as high as 70%. Is there no recurrence with COCP? Also, Medical management after surgery has no added advantage except LNG-IUS can this be used without surgery? which offers some pain relief but cannot be used if desires fertility.

With regards to fertility did the question mention anything about fertility?, IVF is the preferred option for moderate to severe endometriosis with severe adhesions and distorted tubal anatomy and there is no role for just ovarian hyperstimulation in such  cases . Treatment with GnRH analogues 3 to 6 cycles prior to IVF has shown to improve success rates. Removal of endometriomas >4 cm also helps . Success rates for age are slightly lesser in women with endometriosis. Intrauterine insemination would help in mild or minimal endometriosis but not in severe disease and would only waste time and increase couples anxiety. Couple should be involved in decision making .Information Leaflets and contact details of support groups like www.endometriosissociety.org must be provided. See answers above

A] Take detail history of the painful periods and pelvic pain and its effect on quality of life (1). menstrual history such as LMP, regularity , duration of flow , amount of flow and associated dysmenorrhoea .obstretic history such as number of  children and mode of delivery and fertility wishes (1). history of previous contraception used and presently using and any complications associated with it. any contraindication to hormonal contraception  . history of any previous abdominal and pelvic surgeries and any cesaerean sections does CS cause chronic pain / dysmenorrhea?  for intra abdominal adhesions . take sexual history and the associated complications which complications?. medical history of using any treatment for chronic diseases , maigran, any use of enzyme inducing drugs HEALTHY. any history of previous treatment and what was the out come what did the question say?.history of number of sexual partners any recent change of partnerand use of condom during sexual intercourse for sexually transmitted infection . take history to rule out non gynaecological cause of pelvic pain such as  history of bloating, alternate diarrhoea and constipation for irritable bowel symptoms syndrome. any history of weight loss ,loss of appetite ,early satiety and rectal bleeding to rule out malignancy but however malignancy is uncommon in this age group .any history of sexual abuse before . general examination  such as Temperature, pulse, BP BMI . abdominal examination for any tenderness, rebound tenderness , any palpable masses (1). vaginal examination may not detect any pathology , palpate the size of the uterus any tuboovarian mass , CET ??? and palpable nodules on uterosacral ligaments and POD fixed retroverted uterus.Investigations such as blood for LFT, FBC, RFT why??. endocervical  , urethral and rectal swabs for STI . early morning urine sample for PCR  to detect clamydia  why? Symptoms not suggestive of acute PID.TVS  for any ovarian mass endometriomas and abdominal and pelvic pathology such as?? This is too non-specific, this may reassure the patient and detect pathology not identified on vaginal examination . CA 125 may be elevated  but no evidence that it is only due to endometriosis ? meaning. MRI to detect adenomyosis and other pathologies  like what? and endometrial deposits (1). The gold standard investigation is diagnostic laproscopy (1)  ,councel the patient before hand that no cause may be identified in some . endometial deposits can be seen and simultaneously endometrial ablation can be done . risk of surgical exposure  ,bowel , bladder injuries, and injuries to the great vessels .laparoscopy is not only diagnostic but also curative in some patients.

B]  THis requires MDT approach involving gynaecologist, pain clinic , gp. There is medical and surgical management . suppression of ovarian function  reduces endometriosis associated pain but recurrance is common after stopping the treatment. hormonal treatment in the form of combined oral hormonal contraception can be given this not only improves her symptoms such as dysmenorrhoea  but also acts as effective contraception (1) but side effects such as nausea ,vomiting and DVT . LNG ius can be used (1), this decreases her dysmenorrhoea , dysperunia and also act as effective contraception . but irregular bleeding is seen in first few months and amennorhoea in  patients which may not be accepted by the patient .side effects of progesterone such as bloating , headache, breast tenderness may be unacceptable . GNRH analogue for about six months . the treatment is costly is it cost-effective?. this suppresses the ovarian activity  but cannot be used for more than six months since  it decreases the  bone mineral density  by 6 %, however this can be protected by add back therapy in the form of low dose estrogen and progesterone or tibolone  (1). there is  no certainity about the duration of use but can be used upto 2 yrs  .Danazol can be used for upto six months but it has androgenic side effects . medroxy progesterone acetate can be used  this not only relives the symptoms but also act as effective contraception NOT A CONTRACEPTIVE ,but this has progesterogenic side effects which is not accepted by some patients.gestrinone can be used but associated side effects limit its use. surgical treatment such as laproscopic endometrial ablation ??? what is wrong with her endometrium???. this relives symptoms associated with endometriosis but it some patients it does not benefit if disease is due to other cause , incomplete excision, or disease recurrance .  risk of surgical exposure , bowel, bladder damage with endometrial ablation?? . adhesiolysis can be done in case of intra abdominal adhesion but no evidence  that it relives pain .  LUNA dose not reduce endometriosis associated pain . presacral neurectomy can be done but not helpful so why do it? .If the patient has completed her family and has severe symptoms she can have TAH and BSO but she will have premature menopause and needs HRT until age of menopause (1)  . psychological councelling in case of psychosexual abuse . complementary therapies such as reflexology, acupuncture may be benefitted . provide information leaflet and self help support group .

A) Adequate time should be allowed for initial assessment and her therory of the cause of the pain should be disussed.Detalied history about pattern of pain,and relation to the menstrural cycle should be asked how will this help you?.also,if associated or increased by movemnts.i will request from the women to complete  daily pain diary fo 2 to 3 cycles to know provoking fator of the pain.iwill ask about bowel symptoms such as changing in the frequency or the form of the stool.if pain relieved after defetion as it refere to irritable bowel syndrome need to know criteria for IBS.asking about urinary symotoms such as urgency,frequency dysuia, can refer to infection will UTI explain her symptoms?.i would  ask about peristent bloating,changing in the appetite or loss of wight recently as it may refer to ovarian carcinoma.i would senstively ask about past or present sexual assult.moreover i would ask about effect of this pain on her quality of life (1).if associated with lack of sleep.i would ask if the pain make her to be absent from her work.

future pregnancy wishes should be asked as it affects the tratment option (1).

i will perform abdominal examination looking for focal tenderness also to check any abdominal mass (1)

vaginal speculum  to look for any vaginal discharge and if present endocervical swab  should be taken.for diagnosing of chlamydia or gonorrhea.although if swab is negative PID can not be ruled out.

vaginal examination to  detect uterine size ,mobility and detetion of any adenxal mass (1).per rectal examinationif there is history of rectal bleeding to detect nodules in the douglas pouch. which refer to endometriosis.and it better to be examined during menstruation.

i will request FBC ,and CRP as if leucocytosis and raised CRP  refer to infection. Not raised in ‘chronic PID’

i will request transvaginal u/s to check any ovarian cyst,adenxel mass (1).MRI can be used if there is suscpetion of endometriosis or adenomyosis (1).Diagnostic laproscopy better to be  performed after theraputic hormonal trial for 3-6 monthes (1) and possibility of negative finding should be discussed with the woman..

B)If the pain is the main concern of the women. iwould  start by medical treatment .coc pills can be tried first as she had no resonse to simple analgesia.coc can be taken conventially and better to be taken  tricycling (1).also pogestogin also effectine if taken by sufficient dose to induce ammenorrhea (1).side effects include mood changing.breast pain .acne and prolonged use carry risk of decrease bone mineral density (1).danazole is ant estrogen antiprogesterone  can effectively reduce pain but  has androgenic side effect such as hirsutism,acne.breast atrophy. gesternon can also be used twice weekly but it also associated with androgenic side eddfect but kess than danazole.Barrier contraception should be used if gestrinon or danzole are used.

GnRH analouge effectively inhibit ovulation and reduce pain but it carry risk of derease bone mineral density if used more than 6 monthes (1).tibolone can be used as add back therapy to extend use of GnRH up to 2 years (1).

The women should be counselled that no drug is effective more than other drug.but her choice will be as regard side effect of each drug.she should be also councelled that pain relief is not alwayes complete.

Another option is use of leveonorgeteral IUD (1) can effectively decrease pain.finally surgical treatment an be tried .laproscopical ablation of endometriosis and cutting of adhesion associated with improvemnt of the pain (1).Laproscopic uterinenerve ablation is not effective in pain relief.If fertility is not desired and the patient complete her family.pelvic clearnce can be tried (1) if medical and surgical methoda are all failed.written information about the treatment option should be given to the women and offer her support group such as national endometriosis society.

a)Initial assessment involves enquiry about severity of pain, aggravating and relieving factors and  effect on quality of life (1). Take detailed menstrual history about cycle length , regularity , heavy menstrual bleeding. Ask about intermenstrual bleeding post coital bleeding why??. Ask about obstetric history and future reproductive intentions as treatment is given accordingly (1).

Ask about contraception used and need for same. Take sexual history as sexually transmitted infections may cause chronic pelvic inflammatory disease (PID) . Ask about history of sexual abuse and pschycological factors which may cause chronic pelvic pain.  Ask about gastrointestinal symptoms like constipation ,dyschezia bleeding per rectum due to inflammatory bowel disease (1) ? IBS. Ask for urinary symptoms like frequency urgency which may point to interstitial cystitis . Ask about loss of weight appetite ,abdominal distention which may be red flag symptoms for serious pathology. Ask for previous surgery which may cause pain due to adhesions or nerve entrapment.

Ask her to fill validated pain questionnaires and pain diary. Ask for details of previous treatment , cervical smear ? relevance

Examine blood pressure why is this relevant?, BMI. Abdominal examination done for palpable mass, tenderness (1).  Look for pain at bony points like sacroiliac joints, pubis. Speculum examination done for any endometriotic nodules ,polyp. Vaginal examination done for uterine size, adnexal tendeness, nodularity of uterosacral ligaments (1).

Investigations include  cervical, vaginal swabs for sexually transmitted infections like Chlamydia, gonorrhoea will these explain her symptoms?.  Full blood count , CRP,ESR  done if infection suspected. Ca 125 is non specific for endometriosis so will you do it?. Transvaginal scan done to look for adnexal mass, endometriomas, adenomyosis (1).  MRI may be done for adenomyosis can also detect endometriosis. IVP, Barium enema if severe endometriosis suspected  to map extent .

Diagnostic  Laparoscopy (1) is the gold standard for diagnosis of endometriosis but poor correlation between findings and symtoms. Adhesions , endometriomas , endometriotic deposits cna be noted. 

b).  Treatment of moderately severe endometriosis depends on patients wish, desire for fertility , contraception and main complaint. What did the question say?

Medical treatment can be given for pelvic pain. Combined OCP is contraceptive and can be given as cyclical or continous regimen for pain (1) if no contraindications. Progesterone like norethisterone given but additional contraception needed (1) ? dose.

 Depot medroxy progesterone  injections can be given for symptom relief once in 12 weeks. It is contraceptive also (1) any disadvantages?. 

 LNGIUS (mirena) is  helps in symptom relief ,upto 3 years (1).

Gnrh analogues can be used with add back therapy to prevent bone loss.(1) for how long?

Danazol can be used for six months but can cause hirsutism.

Symptom recurrence is common after medical therapy. Surgery needed for endometriomas ? what about ablation of deposits. Laparoscopic  cystectomy done for ovarian endometriomas . Oophorectomy may be needed in severe cases, informed consent should be taken. 

 If fertility not issue bilateral oophorectomy, excision of endometriosis may be done in severe case why retain the uterus???. Severe endometriosis may need referral to centre with expertise to offer advanced laparoscopy .

If fertility is the issue IVF is recommended .No role of medical treatment in fertility treatment . 

Gnrh analogues 3-6 months before IVF improves pregnancy outcome .

Laparoscopic cystectomy before IVF improves access to follicles halts disease progression.  Provide with information leaflets. Give details of support groups like endometriosis UK, pelvic pain support network.