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Essay 310 - Endometriosis

Endometriosis Posted by Shilla Mariah Y.

a) Take a menstrual history, including last menstrual period, to rule out pregnancy. ASk about regularity of menses, amount of flow, and any intermenstrual or postcoital bleeding. Take a history for sexually transmitted infections, such as purulent vaginal discharge, previous pelvic inflammatory disease and sexual history. Take past surgical history, as adhesions can form an cause pain. Ask about urinary symptoms such as dysuria, haematuria, frequency, as urinary tract infections and interstitial cystitis can cause pain. Ask about bowel symptoms such as change in frequency of bowel habit, change in consistency of stool and any rectal bleeding, as bowel disorders such as irritable bowel syndrome can cause pain. Examine the abdomen for any masses and tenderness. Do a speculum examination for purulent discharge or any endometriotic lesions in thje posterior fornix. Do a vaginal examination for cervical tenderness, adnexal masses or tender uterosacral ligaments. Do a rectal examination for rectovaginal nodules, as well as any mass or bleeding. Do a urine pregnancy test if her menses is late. Do a urine dipstick for leucocytes, nitrites and blood for infection or haematuria, and culture if positive. Do an ultrasound pelvis for adnexal masses or uterine lesions such as fibroids or adenomyosis.                                                             b) Gold standard for diagnosis is histology. Positive laparoscopy findings without histology strongly suggest endometriosis, even if histology is negative. A negative laparoscopy makes endometriosis unlikely. Ultrasound finding of an endometrioma makes the diagnosis likely, in the presence of ground glass echogenicity, 1 to 4 locules and absence of papillary structures. A history of dysmenorrhoea, dyspareunia and cyclical pain suggests the presence of endometriosis. Findings of fixed uterus, tender and tethered uterosacrals on vaginal examination and rectovaginal nodules on rectal examination also suggest presence of endometriosis.                                                                                    c) Determine the desire for future fertility. If she desires fertility, refer to a reproductive medicine specialist. If she does not desire fertility, options include medical and surgical treatment. Stronger analgesia can be used to provide pain relief, such as NSAIDs or opioids. Hormonal medications can also decrease pain symptoms. They include combined hormonal contraception, progestogens such as dienogest, and gonadotrophin releasing hormone agonists (GnRH agonists). Combined hormonal contraception provides good cycle control and also contraception, so it is not useful in women desiring future fertility. Progestogens do not provide contraception, so they will need additional contraception. GnRH agonists cause severe ovarian suppression and vasomotor effects such as hot flushes. It also causes loss of bone mineral density with more than 6 months use, so add back hormone therapy is necessary. Surgical treatment include ablation or excision of endometriosis, ablation or excision of endometriomas, and total hysterectomy bilateral salpingo-oophorectomy (THBSO) with clearance of all visible endometriotic lesions. Both excision and ablation of endometriosis improves pain. Cystectomy is superior to ablation or CO2 laser vaporisation of endometriomas in terms of decreasing recurrence. Post operative adjuvant therapy using oral contraceptive pills or Levonorgestrel intrauterine system for 18 to 24 months prevent recurrence of symptoms. THBSO with excision of all visible disease, such as bowel implants, is definitive treatment. However there is high risk of bowel and ureteric, bladder injury. It also removes fertility permanently, and induces menopause. She needs extensive counselling before this operaton including need for hormone replacement therapy.

Posted by MRCOGPASS P.

Clinical assessment should include a history asking about the type of pain, whether it is constant, intermittent and whether it is associated with vaginal discharge or associated with bowel movements, and whether there are any aggravating or relieving factors. Also ask about her menstrual history, whether it is regular, heavy flow, any pre or post menstrual spotting, any intermenstrual bleed and any post coital bleed. Ask about about symptoms such as flatulence, abdominal distension, loose stools to rule out irritable bowel syndrome. Ask about urinary symptoms, hematuria , frequency, urgency which could point to hemorragic cystitis . Ensure cervical smear history is up to date. Enquire about dyspareunia, whether it is deep dyspareunia. Ask about use of any contraceptives as well .Physical examination will include taking her weight, blood pressure and calculating her Body Mass Index. Examine the abdomen and pelvis for any masses. Perform a bimanual vaginal examination to feel for fixed retroverted uterus and any utero sacral nodules or obliteration of the pouch of Douglas. On investigation, an ultrasound pelvis to rule out any ovarian cysts or fibroids as well as a CA-125 level if endometriomas or ovarian cysts detected on scan.

Criteria to diagnose will require histology. Histology can be obtained on a laparoscopy. Biopsies of endometriotic spots/ lesions in the pelvis, removal of endometriomas. resection of utero-sacral nodules will show an infiltrating inflammatory reaction. It can be staged based on the American Fertility scoring system taking into account peritoneal adhesions, ovarian endometriomas, ovarian adhesions, involment of fallopian tube.

 

Treatment can be divided into medical and surgical. 

Medical treatment can be with analgesia such as NSAIDS. Can improve pain control but can cause gastritis. Next is combined oral contraceptive pill. It is effective in cycle control as well as pain control with low side effect profile. However, not suitable if trying to conceive. Progestogens if used in higher doses can cause amenorrhea and good pain control, Howeber, can cause side effects such as weight gain, acne, mood swings and long term usage can cause bone mineral density loss. Danazol can be used . Effective in endometriosis related symptoms control in terms of pain but has side effects such as virilisation, deepening of voice, increase libido and requires an effective contraception.  GnRH agonist induce a menopausal effect and cannot be used for more than 6 months and require add back therapy to prevent bone mineral density loss. The levonorgesterol IUCD can also be inserted. Effective in controlling pain but can cause irregular menstrual bleeding especially in the first few months of use.

Surgical treatments include laparoscopic surgery. Surgery can be performed to confirm the disease. Pelvic endometriosis spots can be ablated with diathermy. ANy endometriomas should be removed , Any endometriotic nodules should also be excised and removed. Other therapies such as Laparoscopic uterine nerve ablation (LUNA) have not been shown to be useful in relieving pain. Pre sacral neurectomy has been shown to be more effective but the surgery carries more risks. Surgery is associated with recurrence of endometriotic spots and endometriomas.

 

 

 

endometriosis Posted by rasheeda B.

Clinical assessment.A detailed history regardingseverity of symptoms and quality of life,needs to be taken.Detailed menstrual history,contraceptive history,current contraception and future needs.Past history of pelvic inflammatory disease and any history of subfertility,obstetric history,gastrointestinal symptoms such as weight loss,bloating,constipation alternating with diarrhoea,rectal bleeding,urinary symptoms including bladder pain,are suggestive of endometriosis.Mood swings and psychological symptoms need to be asked.,as well as details of any abuse.

   Clinical assessment includes checking the abdomen for distension,tenderness,rebound tenderness,abdominopelvic mass.Speculum exam for any nodules seen in vagina,oppurtunity for swabs.Pelvic exam to check for uterine size,position,mobility,adnexal mass,tenderness,cervical excitation,and nodules in rectovaginal septum.Rectal examination if there is rectal bleeding.

b)As per gdg,diagnosis of moderate endometriosis,to be made in presence of dysmenorrhoea,dyspareunia,non cyclic pelvic pain.infertility and fatigue.Also combination of laproscopy and histological verification is the gold standard for diagnosis.A negative laproscopy,in presence of signs and symptoms excludes endometriosis.

c)GDG recommends to counsel her symptoms,presumed to be due to endometriosis and emperically treat withanalgesics and combined hormonal contraceptives or progestogens.Patient"s preference,side effects,efficacy,costs and availability to be taken into consideration,when choosing hormonal treatments for endometriosis pain.Vaginal contraceptive ring or transdermal patch(oestrogen,progestin) to reduce endometriosis associated dysmenorrhoea and chronic pelvic pain .Medroxyprogesterone acetate,dienogest,cyproterone acetate,norethisterone acetate,reduces endometriosis pain.Levonorgesterol IUS,is one option.Also danazol or antiprogestins(gestrinone) to reduce endometriosis pain.Disadvantage of progestins are bloating,bleeding,headache.Danazol disadvantage is acne,hirsuitism,deeping of voice.Gnrh agonist(naferilin,leuprolide,goserline,) are one of the treatment options.But disadvantafe are menopause like symptoms(hot flushes) osteoporosis.But add back therapy with hrt combined type for 6 months can overcome this.Laproscopic deadhesionolysis and removal of endometrioma is also  an option,but recurrences of endometriosis is a set back as well as being invasive and anesthetic and surgical morbidity of laproscope is a disadvantage.

  And finally if a woman has completed her family and wants permanent treatment for her endometriosis pain,hysterectomy with bilateral salpingoopherectomy can be offered.

Endometriosis Posted by farzana S.

A)Symtoms are suggestive of Endometriosis. History should include an enquiry about the cyclical nature of her symptoms and the impact of symptoms on her quality of life. Cyclical hematuria or dyschezia will suggest involvement of bladder and rectum in endometriosis.

Menstrual history is taken about  LMP, age at menarche, regularity of cycle and amount of bleeding.Heavy bleeding with pain could be due to Adenomyosis. Contraception history about current and previous contraceptives. Sexual history about number of sexual partners any recent change in partner, to assess her risk of STIs ,and PID.

Obstetric history about her parity and mode of deliveries.any h/o infertility and her fertility desire , as endometriosis is associated with infertility and her desire for conception would  influence the treatment options.

Surgical history ,any abdominal  or pelvic surgeries may have caused adhesions.

Treatment history ,about the previous treatment , its effectiveness and her compliance is enquired ,also her main concern if it is pain or infertility should be clearly asked ,so that the treatment can be formulated accordingly. History of childhood sexual abuse .Social history for her support system.

On examination ,any abdominal  incision scars or abdomino pelvic mass is noted.Pelvic examination ,speculum examination tolook for bluish black nodules an vaginal walls or cervix.Bimanual examination for Uterine position and mobility as the uterus may be fixed and retroverted.Endometriotic nodules are felt on uterosacral ligents.Pelvic tenderness and adnexal mass is noted  for endometriomas.Rectovaginal palpation for induration and deep infiltrating lesions.

B)Diagnosis of endometriosis is made on laparoscopy by visual inspecton  of endometriotic nodules on pelvic ,abdominal peritoneum and ovaries ,endometriomas may be found on ovaries.

Biopsy of the nodules may be taken for histology and confirmation .Adhesions may be found, which may be thin or dense. Pictures should be taken. American fertility society has classified endometriosis based on presence of adhesions ,thin or dense on abdominal or pelvic peritoneum ,ovaries and tubes, presense of  endometriomas .A score of 6-15 for moderate  and  score of 16-30 is given for  severe endomeriosis. MRI may be required to assess extent of deep infiltrating endometriotic lesions in the recto vaginal region or bladder involvement.

C)Woman ‘s concerns and expectations should be explored ,whether her main concern is relief of pain or infertility.If she has used NSAIDs  with no effect further options include medical treatment  i.e hormonal or surgical.

Hormonal treatment is effective in relief of pain ,but all are contraceptive ,hence would not be  treatment of choice if she is planning to conceive. These  are very effective in relieving pain by suppression of ovarian activity,but differ in side effect profile ,cost and availability.COCP may be taken cyclical or tricyclic basis. Less expensive but need compliance for daily use. Side effects include increased risk of cardiovascular disease and VTE.

Progestogens  taken daily in high dose,DMPA or LNG-IUS  provide  amenorrhea  and effective pain relief. Side effects include weight gain, mood changes, depression, headache and acne.may also loss of bone mineral density. Danazol is androgenic steroid , its use is limited by its androgenic side effects i.e weight gain,acne,hirsutism and  irreversible deepening of voice .Risk of benign hepatic adenoma.Gestrinone is anti- progestogenic and anti-estrogenic.This is an effective alternative to progestogens as it does not cause  loss of BMD.Androgenic effects are milder than Danazol.

GnRHa  can cause loss of BMD if used more than 6m,but may be used for 2yrs with add back therapy.

Surgical treatment includes laparoscopy and adhesiolysis or ablation of endometriotic nodules.She should be reffered to a centre with multidisciplinary input ,and adequate assessment of bowel ,bladder and ureteric involvement by MRI,TVS or trans rectal USS and ,IVP and barium enema..Endometriomas more than 3cm should be removed by cystectomy.Surgical treatment is helpful not only for pain relief but also helps in achieving hiher pregnanacy rates spontaneously or by ART. Risks include anesthetic ,and visceral and vascular injury, pain may recur or sub optimally relieved .If she has completed her family, hysterectomy is an option for relief of her pain.

Posted by Saf S.
A: clinical assessment would involve history and examination .I would asked regarding nature of pain ,cyclical,duration,aggravating,relieving factors. Also ,enquire about bowel habits ,any bowel disturbance would indicate GI involvement. Any history of haematuria may indicate bladder disease.A detailed menstural history ,age at menarche , regularity , flow, cycle would help in diagnosis. Also asked regarding nature of dysparunea either deep or superficial as deep is associated with endometriosis. Moreover would asked regarding any medical disease. Surgical history would exclude possibility of adhesions . Next ,would perform examination general physical to check BMI ,any scar marks.abdominal examination may reveal any mass , hernia. Pelvic examination to assess position of uterus ,mobility,tenderness,consistency ,size. As fixed retroverted uterus may indicate endometriosis, large irregular uterus may be indicative of fibroids . Any tenderness and palpable endometrial nodules at uterosacral ligaments is suggestive of endometriosis .Speculum examination may reveal visible endometrial lesions. B: laparoscopy is the gold standard investigation for diagnosis of endometriosis .Visual inspection of endometrial lesions and endometrioma. Histology may be helpful ,a positive histology confirmed endometriosis but negative histology would not exclude it. American fertility society classified endometriosis on basis of pelvic and abdominal lesions,presence of adhesions and type of adhesions thin or dense. It is useful in determining severity of disease. A TVS scan may indicate endometrioma, but deeply infiltrated nodules would be noted with MRI. C: Treatment would be medical and surgical . Medical management will include analgesics , non opioid, NSAIDs advise that it may suppress ovulation ,should be avoided if any fertility desire. Hormonal treatments are combined oral contraceptive pills ,can be taken cyclical or back to back. It is not a suitable option if trying to conceive ,although it has proven benifits in reducing pain and cycle control with low adverse profile. Levonorgestrel intrauterine system is yet another option to refuse pain and control symptoms , associated with irregular bleeding in initial ~6 months of treatment. Danazol is effective in controlling pain but associated with serious side effects e.g : viralisation deepening of voice,would require contraception along treatment. In addition GnRH analogue would be useful in suppressing ovulation and alleviating symptoms can be given for 6 months upto 2 years with add back therapy(to avoid bone mineral density loss) . Associated with menopausal effects and osteoporosis. Surgical options are laproscopic ablation and cystectomy of endometrioma , it is less invasive procedure with avoidance of major surgery ,less hospital stay and lower risk of infection. Cystectomy is preferred over drainage , as the former is associated with less risk of disease recurrence and high patient satisfaction. Moreover laparoscopically Per sacral nerve ablation is proven to be helpful in some cases. If patient has no fertility desire and has completed her family , total abdominal hystrectomy and bilateral oophorectomy may be disease curative . It would be offered after counselling of persistent pain even after surgery and trial of GnRH.
Posted by ixi C.

a)

Take a menstrual history for last menstrual period, flow, cycle length and regularity. Ask about dysmenorrhoea and its severity and whether it affects her quality of life. Take a history about dyspareunia, determine if it is superfical or deep dyspareunia. Ask about vaginal dryness and sexual dysfunction. Take obstetric history for parity. Ask about fertility wishes. Take gynaecological history for previous contraceptive use, smear history and previous surgeries. Ask about smoking and alcohol use. Take family and personal history of venous thromboembolism and migraines, as these may affect treatment options. Ask about symptoms of vaginal discharge and previous history of acute pelvic inflammatory disease. Take a sexual history for number of sexual partners. Ask for associated urinary and bowel symptoms such as bladder pain and dyschezia. Take blood pressure and calculate body mass index. Do abdominal examination for masses. Examine vulva and vagina to look for superficial lesions which may cause dyspareunia. Do vaginal examination to look for retroverted fixed uterus, adnexal mass, thickened uterosacral ligaments. Do per rectal examination to look for rectovaginal nodules. Perform ultrasound pelvis to look for endometriomas.

b)

Gold standard for diagnosis of endometriosis is by diagnostic laparoscopy. Evidence of deep infiltrating peritoneal nodules, tubal damange due to endometriosis, ovarian endometriomas or endometriotic deposits affecting ureters or bowel support the diagnosis of moderately-severe endometriosis. 

c)

Medical treatment with combined oral contraceptive pills will reduce mentrual flow and improve dysmenorrhoea. However this is unsuitable if she is keen for fertility. There is also an associated risk of venous thromboembolism and may not be suitable if she is obese (UKMEC3 for BMI >35) or a smoker of more than 15 cigarettes a day. Progestogens such as medroxyprogesterone acetate are an alternative. These also affect fertility and are not suitable if fertility is desired. They also cause side effects of weight gain, bloating, and headaches. Antiprogestogens such as danazol may be used. However, these should be limited to 6 months duration and require effective contraception in view of the risk of virilization of a female fetus. Side effects include acne, greasy skin, breast atrophy and musculoskeletal pains. Levonorgestrel intrauterine system is benefical in reducing pain and menstrual flow, but is also a contraceptive method. GnRH agonists may be given but use should be limited to 6 months duration in view of risk of bone loss. Side effects include menopausal symptoms such as vasomotor symptoms and mood swings. Laparoscopy and excision or ablation of emdometriosis may be carried out. This will reduce pain but may be associated with increased morbidity especially in deeply infiltrative lesions. Multidisciplinary team approach with urologists and surgeons may be required. Hysterectomy and bilateral salpingoophorectomy may be considered but this will result in surgical menopause and precludes fertility. Hormone replacement therapy may be required. 

Endometriosis Posted by Maili Q.

(1)

I would assess the severity of pain and impact on quality of life and daily function. I would ask about menstrual history, including regularity, menstrual flow, and last menstrual period. Sexual history would include numbers of partners (risk of STD), and need for contraception. Fertility intention is important when planning treatment. Gastrointestinal symptoms like dyspepsia, alternating diarrhoea and constipation may suggest irritable bowel syndrome. Dysuria, urinary frequency or urgency and suprapubic pain would suggest urinary tract infection or interstitial cystitis. On physical examination, body mass index should be recorded as may limit the choice of treatment. Abdomen should be palpated for tenderness or mass. Speculum should be performed to look for deep infiltrated endometriosis. Pelvic examination should focus on uterine or adnexal tenderness, mobility of the uterus, tender nodularity in pouch of Douglas. 

(2)

This is a laparoscopic diagnosis during which severity of endometriosis is assessed based on peritoneal, periovairan, and peritubal adhesion, ovarian endometrioma and tubal patency using a scoring system. A score of 6-15 or above is considered moderate to severe endometriosis as suggested by American Fertility Society. There is poor correlation between the stage and clinical symptoms.

(3)

Empirical treatment with hormonal contraceptives, progesterones and GnRHa are of similar effectiveness in treating endometriosis-associated pain. Possibility of recurrence after discontinuation should be explained. They are not suitable if patient is seeking conception.

Combined oral contraceptive pills can reduce endometriosis related dysmenorrhea, dyspareunia and non-menstrual pain, especially when taken continuously or tricyclically. It also offers reliable contraception. 

Progesterones or anti-progesterones including medroxyprogesterone acetate (oral or depot), dienogest, cyproterone, norethisterone, and gestrinone are used at a dose to induce amenorrhea in order to reduce endometriosis-associated pain. Different side effect profiles should be explained, including irregular bleeding, weight gain, bloating, mood change, thrombosis, and androgenic effects. DMP is associated with delayed return of fertility after discontinuation and loss of bone density after prolonged usage.

LNG-IUS is an effective long-term treatment option (up to 3 years) and is of contraceptive value. It also has the side effect of irregular bleeding.

GnRHa is one of the options for reducing endometriosis associated pain, although evidence regarding duration or dosage is limited. Add back therapy should be administered to prevent bone loss and menopausal symptoms during treatment.

 

Surgical treatment with laparoscopic ablation and excision of endometriosis is effective to reduce pain and improve fertility. Procedure related risk including visceral injuries and reduced ovarian reserve after cystectomy should be explained. Patient should be informed of the risk of recurrence of symptoms. There might be a role for long term (at least 18-24 months) combined hormonal contraceptive or LNG-IUS after surgery to prevent recurrence of endometriosis-associated dysmenorrhea, but non-menstrual pain or dyspareunia. Definitive treatment of hysterectomy + bilateral salpingo-oophorectomy + excision of endometriotic lesions with postoperative HRT is preserved for those who have failed conservative treatment and completed family. But patient should be informed that surgery may not cure the pain.

Posted by toothless ..

a) I would take a menstrual history including last menstrual period, duration, flow, regularity. Associated symptoms of change in stool caliber and frequency, dysuria and hematuria, vaginal discharge should be asked to exclude differentials of irritable bowel syndrome, interstitial cystitis, pelvic inflammatory disease. Red flag symptoms of recent weight loss and per rectal bleeding is important. The impact of pain on the patient's daily activities, work and social life should be asked, together with obstetric history and future fertility intentions. I would ask for past medical history, surgical history, smoking, alcohol. I would do an abdominal examination looking for surgical scars and abdominal masses. Speculum exam for endometriotic nodules in the posterior fornix, vaginal examination for uterine size, tenderness, mobility, adnexal masses, uterosacral nodules should be done. A per rectal exam may be considered if bowel symptoms present.

b) The criteria for diagnosis if surgical staging by the American Fertility Society scoring system. Diagnostic and/or therapeutic laparoscopy is carried out and the pelvis carefully inspected for endometriotic deposits and adhesions. Total score for peritoneal deposits and adhesions, tubal depositis and adhesions, ovarian depositis and adhesion is added up. Patients are stratified according to the total score into minimal, mild, moderate, severe disease.

c) The treatment options depends on the patient's primary concerns and fertility wishes. Hormonal medical treatment may be undertaken if not keen for fertility. Combined hormonal contraceptives may be used for alleviation of dysmenorrhea, dyspareunia. Oral, vaginal ring and patch may be used cyclically or tri-cyclically. Progestogens including medroxyprogesterone acetate and dienogest is another option for pain relief. Side effects include irregular bleeding, weight gain. Danazol may be used but is associated with side effects of acne, hirsutism, bloating. Anti-progestogen agents like Gestrinone or levonorgestrel intra uterine system may be used. GNRH agonists like Goserelin have side effects of hot flushes, vaginal dryness and may lead to decreased bone mineral density. Add back therapy with estrogen and progesterone on initiation protects against bone loss. Surgical treatment may be considered in case of  failed medical treatment. Pre operative investigations include transvaginal ultrasound and further imaging modalities including MRI, cystoscopy, urogram may be required as guided by patient's symptoms and their severity. A multidisciplinary team input including colorectal surgeons and urologist may be necessary in deep infiltrative disease. Therapeutic laparoscopy with cystectomy of endometriomas, division of dense adhesions and resection or ablation of endometriotic deposits may be done. In severe symptoms and no further wish for fertility, hysterectomy may be considered with ovarian preservation or oopherectomy with subsequent hormonal replacement therapy. Written information should be given and contact details for support groups given.

Posted by rukshana H.

 healthy 35 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during intercourse. Her symptoms have not responded to simple analgesia. (a) Discuss your clinical assessment [6 marks]. (b) She is found to have moderately severe endometriosis. Discuss the criteria for making this diagnosis [4 marks]. (c) Discuss and justify her treatment options [10 marks]

 

Pelvic pain caused by conditions such as endometriosis, chronic PID, Genital tract malignancy & non gynae pathology of Bowel and Bladder. Impact of pain on quality of life should be asked. Vaginal discharge with pelvic pain suggests PID. Symptoms of malignancy like loss of weight, appetite, is enquired. Bladder symptoms of frequency, urgency & haematuria is noted. Gastro-intestinal symptoms like diarrhea, change in frequency, pain relief after defecation suggest irritable bowel syndrome. Menstrual history of painful cycles with flooding signifies endometriosis with adenomyosis. Red flag symptoms should be asked about. Parity and Fertility wishes should be noted. Contraception current and future requirement asked. History of sexual abuse and psycho sexual problems is explored sensitively. Details of STI status in partner and woman is enquired. Change of partner in last one year and more than one partner in a year is high risk for STI. Quick review of treatment records, STI and CX screening results done.

Laparoscopy is the diagnostic modality of choice. Features of moderate to severe endometriosis includes peritoneal deposits of powder burn, red in-plants, and fibrotic areas. Peritubal adhesions on each side scored individually. Total score of 16-40 designated as moderate endometriosis. More than 40 is severe. This scoring is as per American Society for reproductive medicine  classification. This criteria does not reflect on the symptoms of endometriosis.

The treatment depends on fertility wishes , severity of symptoms and should take into consideration requests for non surgical and alternative treatment modalities. If Fertility not a priority, medical methods preferred. Combined oral contraceptive and progesterone are of equal efficacy but with varying side effects profile. Combined pills offered in continuous or extended regime, associated with risk of VTE. Nausea, weight gain and GI upset are side effects. Cheap and effective method. Progestrone in dose of 10-30 mg/day, associated with slight increase in breast cancer risk (additional risk of 8 per 1000 women). Implants and injectables cause weight gain of 2-3 kg/year and abnormal bleeding pattern. LNG IUS releases 20 mg/day used upto 4 years effective for control of deep endiometrosis in particular. Causes amenorrhea in 80% of women. But irregular bleeding is seen in first 6 months of use. GnRH analogs second line option, due to menopausal symptoms. Add back therapy with E+P or tibolone adviced to prevent bone loss.. Laparascopy with ablation of deposits and excision of endometriomas of more than 4cms reduces pelvic pain by 60-70%,If the woman has fertility issues It is  recommended prior to IVF , improves pregnancy rates. Alternative treatment like reflexology and acupuncture are of doubtful efficacy the women should be counseled prior .

sorry the previous answer was incomplete Posted by rukshana H.

 healthy 35 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during intercourse. Her symptoms have not responded to simple analgesia. (a) Discuss your clinical assessment [6 marks]. (b) She is found to have moderately severe endometriosis. Discuss the criteria for making this diagnosis [4 marks]. (c) Discuss and justify her treatment options [10 marks]

 

Pelvic pain caused by conditions such as endometriosis, chronic PID, Genital tract malignancy & non gynae pathology of Bowel and Bladder. Impact of pain on quality of life should be asked. Vaginal discharge with pelvic pain suggests PID. Symptoms of malignancy like loss of weight, appetite, is enquired. Bladder symptoms of frequency, urgency & haematuria is noted. Gastro-intestinal symptoms like diarrhea, change in frequency, pain relief after defecation suggest irritable bowel syndrome. Menstrual history of painful cycles with flooding signifies endometriosis with adenomyosis. Red flag symptoms should be asked about. Parity and Fertility wishes should be noted. Contraception current and future requirement asked. History of sexual abuse and psycho sexual problems is explored sensitively. Details of STI status in partner and woman is enquired. Change of partner in last one year and more than one partner in a year is high risk for STI. Quick review of treatment records, STI and CX screening results done.Blood pressure, BMI checked. Abdomen palpated for mass,tenderness and organomegaly. Speculm examination for vaginal nodules of endometriosis.Bimanual examination for uterine size ,mobility,  adnexal mass, tenderness .Rectovaginal examination for endometriosis of septum. 

Laparoscopy is the diagnostic modality of choice. Features of moderate to severe endometriosis includes peritoneal deposits of powder burn, red in-plants, and fibrotic areas. Peritubal adhesions on each side scored individually. Total score of 16-40 designated as moderate endometriosis. More than 40 is severe. This scoring is as per American Society for reproductive medicine  classification. This criteria does not reflect on the symptoms of endometriosis.

The treatment depends on fertility wishes , severity of symptoms and should take into consideration requests for non surgical and alternative treatment modalities. If Fertility not a priority, medical methods preferred. Combined oral contraceptive and progesterone are of equal efficacy but with varying side effects profile. Combined pills offered in continuous or extended regime, associated with risk of VTE. Nausea, weight gain and GI upset are side effects. Cheap and effective method. Progestrone in dose of 10-30 mg/day, associated with slight increase in breast cancer risk (additional risk of 8 per 1000 women). Implants and injectables cause weight gain of 2-3 kg/year and abnormal bleeding pattern. LNG IUS releases 20 mg/day used upto 4 years effective for control of deep endiometrosis in particular. Causes amenorrhea in 80% of women. But irregular bleeding is seen in first 6 months of use. GnRH analogs second line option, due to menopausal symptoms. Add back therapy with E+P or tibolone adviced to prevent bone loss.. Laparascopy with ablation of deposits and excision of endometriomas of more than 4cms reduces pelvic pain by 60-70%,If the woman has fertility issues It is  recommended prior to IVF , improves pregnancy rates. Alternative treatment like reflexology and acupuncture are of doubtful efficacy the women should be counseled prior .

Posted by Aliwal S.

(a) Take a history about the severity of pain and effect on quality of life. Any associated bowel symptoms like dyschezia, or bowel habit changes, and any urinary frequency or dysuria for urinary tract infections. Take a menstrual history including last menstrual period, regularity, cycle length and flow. Ask about current or past drugs tried and effectiveness. Take an obstetric history, previous pregnancies, current fertility wishes and any contraception used now. History of sexually transmitted diseases and number of sexual partners, or any current vaginal discharge could indicate risk of pelvic inflammatory disease. On examination, abdominal examination looking for masses and tenderness. Speculum examination looking for vaginal endometriotic nodules, and vaginal pelvic examination for pelvic adnexal masses, uterosacral tenderness and nodules, and mobility and position of uterus. 

(b) Diagnosis is by laparoscopic surgery and biopsy and histology of endometriotic lesions. A positive histology confirms the diagnosis but a negative biopsy does not exclude it. Score of disease based on American Fertility Society (AFS) system, based on severity of disease of peritoneal adhesions and lesions, endometriomas and ovarian lesions, tubal involvement, damage or occlusion. A score of 16-30 is moderate, and >30 is severe disease

(c) Her pain can be treated by analgesics such as NSAIDS, which have shown to help for primary dysmenorrhoea and may be useful in endometriosis. However, may be associated with gastric side effects. Hormonal methods like combined hormonal contraception (in the form of pill, patch or ring) can be used to improve pain, help cycle control, and provide contraception if desired. However, not for patient's trying to conceive. Progestogens can be administered orally (dienogest) but associated with progestogenic side effects of bloatedness. IM medroxyprogestogen acetate can decrease pain and dysmenorrhoea, last for 12 weeks each time, making it more convenient than daily pill taking, but alos associated with weight gain, bone loss with long term use, and irregular bleeding. Levonorgestrel intrauterine system (LNG-IUS) can provide longer relief with use up to 5 years, contraceptive effects, decreased progestogenic side effects compared to other progestogens, but associated with irregular bleeding for first few months of use. Antiprogestogens like danazol have shown to improve pain but associated with severe androgenic side effects like acne, hirsuitism, and requires use with effective contraception due to risk of virilisation of fetus. GnRH agonists are effetive for pain but come with hypoestrogenic menopausal symptoms and bone loss, requiring the use of addback hormonal therapy.

Surgical methods like laparoscopic excision or ablation of endometriotic lesions can decrease pain. Laparoscopic surgery equivalent to laparotomy in effectiveness but with shorter stay and quicker recovery. Cystectomy of endometriomas can decrease pain and recurrence of disease compared to drainage and coagulation. Presacral neurectomy can be useful as an adjunct treatment, but mainly for midline pain and associated with constipation and urinary urgency. Hysterectomy with bilateral oophorectomy with replacement hormonal replacement therapy is an option if failed medical treatment and completed family. However, need to explain that it may not reduce all pain. All surgery associated with risks of damage to viscera, anaesthtic risks, and recurrence of disease of almost 50%. Postsurgical long term hormonal therapy can help to decrease recurrence of symptoms and disease, with use of oral contraceptive pills for 18-24 months, or LNG-IUS device.

Posted by Di T.
A. I will ask about her last menstrual period and if the pain associated with cyclical or continuous pain. It is associated with haematuria and bleeding per rectal during her menses. Change in bowel habit should also be asked. Associated abnormal vaginal discharge will also be explored. Exploration of how the disease severity and effect to her life style is also important. I will ask about her contraception use and intension for fertility. I would also ask the medication history of what she has been tried and how is the respond. Per abdominal examination should be done to look for associated pelvic mass such as fibroid, ovarian cyst and their mobility. Tenderness should also be noted. Per vaginal examination to look for any abnormal per vaginal discharge should be done. I will also do bimanual examination to see if uterus is retroverted, tenderness and any adnexa mass and uterosacral ligament thickenss / nodules if there are present, it would likely suggest endometriosis. B. Base on the finding on the laparoscopic / laparotomy , the severity of the disease is score on location of the endometriosis, the size of endometriosis, depth of its infiltration, and degress of adhesion. Based on the score, it is grade into stage I to IV. C. Analgesic such as NSAID can also be prescribed. It should to inhibit ovulation when taken at mid cycle. Gastritis is the side effect. Combine oral contraception pill can also be prescribed as cyclical or continue tricyclical. They have contraceptive properties as well as regulating the cycle if it is associated with irregular cycle. Medical history such, cardiac disease, deep vein thrombosis should be explore prior to describing the COCP as they are contraindicated with it. Progesterone in the form of depot medroxyprogesterone can be given to supress ovulation hence pain improvement. Weight gain, headache and nausea is common side effect. Gonadotropin releasing hormone analogues (GnRHa) can be given 3-6months. Loss of reversible bone density if use for long term, and hot flushes therefore add back therapy is recommended. Levonogestral intrauterine system can be inserted as has beneficial effect in reducing the pain. It can cause irregular bleeding. Danazol can be used however it can use irreversible voice change. Surgical treatment includes total abdominal hysterectomy and bilateral salphingoophorectomy. It should not be done without prior GnRHa and its respond. She should also be explained that it is not necessarily cured the pain. Ablation of endometriosis lesion can improve the pain. Endometrioma of >4cm should be removed. Laparoscopic uterine nerve ablation on its own does not improve the pain and associated with uterine prolapse later.