Makindo Medical Notes.com

Laparoscopy is the gold standard diagnostic test for endometriosis is based on the Royal College of Obstetrician and Gynaecologists guideline. Subfertility may be due to distortion of pelvic anatomy due to adhesions or endometriomas, or disturbance of reproductive processes.

About

• Endometrial like tissue found outside the uterus
• Usually found in the pelvis but can be seen in distal sites

Aetiology

• Ectopic reflex and implantation, Vascular/lymph spread
• Transformation of tissues vagina, cervix, and bladder, lung, brain, local scarring and inflammation
• Most deposits are in the pelvis, and is oestrogen-dependent and responds to the hormonal changes of the menstrual cycle.

Clinical

• Age usually 30-40 year old uncommon < 20 years old
• Most women with endometriosis have no symptoms
• Pelvic pain and painful periods, painful intercourse
• Heavy periods, infertility, haemoptysis, epistaxis
• Bowel and bladder symptoms, painful defaecation
• Pelvic tenderness, painful intercourse
• Pelvic examination is likely to be normal. Advanced disease may cause pelvic tenderness.

Investigations

• FBC, U&E, LFTs, Pregnancy test
• Culture any discharge
• Transvaginal USS
• Diagnostic laparoscopy is key and needs a Gynaecology referral

Primary Care Management

• Referral to a Gynaecologist to confirm the diagnosis by laparoscopy, and for consideration of medical or surgical treatment. Exclude an STI and PID and pregnancy if sexually active
• Analgesia for pain - NSAID such as ibuprofen, naproxen, or mefenamic acid unless contraindicated. Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient.
• If the woman does not wish to conceive, consider prescribing a 3-6 month trial of hormonal contraception (off-label use): Monophasic combined oral contraceptive (COC) preparations containing 30-35 micrograms of ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually the first choice. Advise the woman to start a 3-month trial of a conventional regimen, then switch to tricycling or continuous use if this does not control symptoms. Oral (desogestrel 75 micrograms), depot (Depo-Provera), subdermal implant (Nexplanon), and intrauterine progestogen-only (Mirena) contraceptives may also be considered, after a full discussion of the advantages and disadvantages. If the woman does not want to take hormonal contraception, offer an oral progestogen, such as Medroxyprogesterone or norethisterone.
• Review the woman after 3 to 6 months (earlier if symptoms are troublesome). Refer to a Gynaecologist if there is no improvement in symptoms after a 3-to-6-month trial of treatment in primary care

Secondary Care

• Specialist hormonal treatments may be used. Gonadotrophin-releasing hormone (GnRH) analogues cause pituitary down-regulation with anovulation and amenorrhoea, which induces a reversible menopausal state and regression of endometriosis deposits. Add-back hormone replacement therapy (HRT) should be initiated in secondary care for women taking GnRH analogues, or following hysterectomy and/or bilateral salpingo-oophorectomy surgery for endometriosis.
• Tibolone or combined progestogen plus oestrogen HRT can be used for women taking GnRH analogues to reduce the risk of postmenopausal symptoms and bone mineral density loss adverse effects.
• The choice of HRT options following hysterectomy and/or bilateral salpingo-oophorectomy for endometriosis symptoms is a specialist decision that should be made in secondary care.
• Surgical options: Laparoscopic surgery (includes diathermy, laser ablation or excision of deposits, ovarian cystectomy) ideally done at the time of initial diagnostic laparoscopy. Radical surgery (such as total abdominal hysterectomy and salpingo-oophorectomy with the removal of all visible endometriosis lesions) in women who have completed their families when other treatments have failed.

References

• NICE Guidance Endometriosis 2014