Endometriosis

Overview

• Oestrogen-dependent inflammatory condition

• Endometrial cells outside the uterus

• Progressive, recurrent and debilitating

• 5 to 10% of women

• 20 to 50% of infertile women

• 3 to 10 x increase in risk if a first-degree relative affected

• 70 to 85% of women with chronic pelvic pain

Pathogenesis

• Not well understood

• Retrograde menstruation

• Haematogenous or lymphatic spread

• Iatrogenic dissemination (LUSCS scars and port sites)

• Genetic predisposition

Symptoms

• Pain

  • Dysmenorrhoea 90%

  • Ovulation pain

  • Deep dyspareunia 75%

  • Chronic pelvic pain 70%

  • Pain during examination

  • Deep lower back pain (uterosacral ligament disease)

• Bleeding

  • Heavy, irregular, extended of PCB +/- clots

  • Dark or old blood at the start or end of period

• Bowel / Bladder

  • Cyclic bowel or bladder symptoms (constipation, diarrhoea)

  • Pain before or after opening bowels

  • Pain before or after urination

  • Bleeding for the bowel

  • Blood in urine

  • IBS type symptoms

• Other

  • Chronic fatigue, tiredness, bloating

  • Infertility 55%

  • Fainting during period

  • Nausea

  • Depression

Infertility

• 50% of infertile women have Endo

Sites

• Peritoneum, ovaries, fallopian tubes

• Ligaments, POD

• Bladder and bowel

• REctovaginal septum

• Abdominal surgery scars and outside pelvis (liver, lungs, nose)

Early Dx

• Average of 7 years delayed diagnosis

• 13 years for the deep infiltrative disease

• Progressive

• Reasons for delay

  • Belief that period pain is normal = not true

  • Belief that endo is a disease in older women = not true, can be present from menarche

  • Symptoms non-specific

  • Physical exam is often normal

  • Diagnosis needs laparoscopy officially

History

• Present and past menstruation

• Family history Endo

• Pain very useful

• Disease stimulated by hormones

• Talk with adolescents with parent and separately

• Early menarche is associated

• Symptoms progress with time

• Pain location and severity

Exam

• Palpation for deep abdomen tenderness

• Vaginal exam if appropriate for tenderness, uterine size, nodules, ovarian cysts

Imaging

• Pelvic U/S

DDx

• Exclude STI, ectopic, PID, ovarian torsion, IBS

Referral

• Severe dysmenorrhoea

• Period pain not managed with NSAIDs or OCP

• Presents with a range of non-specific symptoms including dysmenorrhoea

• Arrange review at 3 months, with long consult to debrief after suspected diagnosis

Managing Pain

Endo-associated pain may be

• Recurrent Endo

• Recurrent pelvic pain

• Related to chronic pain syndrome

Multidisciplinary team

• Analgesia including NSAIDs

• Endo pain suppression

  • OCP, Nuvaring, Implanon, Mirena, Depot

• Pain management with Endep, Cymbalta, Lyrica

• Physio

• GnRH agonists prescribed by Gynae

• Progestogens and anti-progestogens

• Pain specialists

• Avoid recurrent surgery if refractory to symptoms

Lifestyle

• Physical activity reduces pain and improves wellbeing

Complementary

• Evidence not well established for acupuncture, TENS, Magenseium, Bitamin B1, B6, and fish oil

Mental health

References

• Endometriosis Tool - Jean Hailles

• Endo Webinar - 90min - Jean Hailles

• Endometriosis Clinical Guidelines - RANZCOG