Malady Wise

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Endometriosis

Maladywise

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