questions 6

Endometriosis

Topic updated on 03/08/17 11:40am

Snapshot
  • A 29-year-old nulligravida presents with severe pain with menses and an inability to conceive after 24 months of unprotected intercourse. She reports feeling pain with defecation and intercourse. On pelvic exam, her uterus is found to be retroverted and there is nodularity of the uterosacral ligament on retrovaginal examination.
Introduction
  • Clinical definition
    • a nonmalignant condition where the endometrial glands and stroma are located outside of the uterus
  • Epidemiology
    • incidence
      • 7-10% of women in the US
    • demographics
      • only in female
      • most commonly in those 25-29 years of age
    • location
      • ovaries (most common)
      • uterosacral ligaments
      • retrouterine pouch (pouch of Douglas)
      • peritoneum
    • risk factors
      • family history
      • early menarche
      • nulliparity
  • Pathophysiology
    • pathobiology
      • ectopic endometrial tissue leads to an estrogen-stimulated inflammatory response
  • Associated conditions
    • chronic pelvic pain
    • endometrioma ("chocolate cyst")
      • endometriosis affecting the ovary
    • subfertility
  • Prognosis
    • natural history of disease
      • endometriosis may self-stabilize without treatment; however,
        • this may be a progressive, relapsing, or chronic condition
Presentation
  • Symptoms
    • dysmenorrhea
    • dyspareunia (painful intercourse)
    • dyschezia (painful defecation)
    • infertility
    • chronic pelvic pain
  • Physical exam
    • nodular thickening of uterosacral ligament
    • a fixed retroverted uterus
    • tender, fixed adnexal masses
Imaging
  • Ultrasonography
    • indications
      • first-line imaging modality to assess for endometriosis
Studies
  • Laparoscopic visualization with histologic confirmation
    • provides definitive diagnosis of endometriosis
    • classically may see "powder burn" appearance
  • Histology
    • endometrial glandular tissue
Differential
  • Adenomyosis
  • Endometritis
  • Ovarian torsion
Treatment
  • Medical
    • combined hormonal or progestin-only contraceptives
      • indications
        • considered first-line for pain due to endometriosis
    • gonadotropin-releasing hormone (GnRH) agonist
      • indications
        • second-line treatment for endometriosis
      • mechanism
        • inhibits gonadotropin secretion which
          • decreases FSH and LH levels leading to a suppression of ovarian function
    • levonorgestrel-releasing intrauterine device (IUD)
      • indications
        • another second-line treatment for endometriosis
    • danazol
      • indications
        • not commonly used due to side-effects
      • mechanism
        • suppreses FSH and LH pituitary secretion
  • Operative
    • laparoscopic ablation 
      • indications
        • surgery is the only definitive treatment and diagnostic modality
    • total abdominal hysterectomy with lysis of adhesions
      • indications
        • in patients who have completed childbearing with severe and recurrent disease
Complications
  • Complications
    • infertility


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Qbank (5 Questions)

TAG
(M2.GN.3) A 27-year-old woman presents with pain during sexual intercourse. She also reports severe menstrual-related pain. Around the time of her periods, she complains of pain with bowel movements or urination. She has no significant past medical history. Vital signs are stable. Physical exam reveals no palpable masses and a pelvic exam which is within normal limits. Which of the following is true about this woman's condition? Topic Review Topic

1. This condition is associated with insulin resistance
2. The patient is at a greater risk of infertility
3. The patient is at a greater risk of ovarian or breast cancer
4. This patient should be referred for a hysterectomy
5. Having multiple children is a risk factor for this illness

PREFERRED RESPONSE ▶
TAG
(M2.GN.80) A 27-year-old nulligravida female presents to her primary care doctor with heavy, painful periods and dyspareunia. She notes that she is recently divorced, but she did not become pregnant after having unprotected sex for two years with her ex-husband. She has a significant family history of painful periods and believes her mother underwent surgery for her condition. Which of the following is LEAST likely to be effective in treatment for this patient's pain? Topic Review Topic

1. Combined oral contraceptive pill
2. Estrogen-only oral contraceptive pill
3. Danazol
4. Gonadotropin-releasing hormone agonists
5. Non-steroidal anti-inflammatory medications

PREFERRED RESPONSE ▶
TAG
(M2.GN.80) A 27-year-old G0 female presents with chronic pelvic pain and severe, disabling cramps during menstruation. She says that these symptoms have been present for several years but have recently worsened. Her past gynecological history is notable for infertility despite unprotected intercourse with her husband for two years. Pelvic exam demonstrates nodularity of the uterosacral ligament. Which of the following is the most likely to confirm the diagnosis for this patient? Topic Review Topic

1. Abdominal CT scan
2. Transvaginal ultrasound
3. Intrauterine insemination
4. Clomiphene citrate
5. Visualization of extrauterine implants

PREFERRED RESPONSE ▶
TAG
(M2.GN.137) A 26-year-old nulligravida female presents to her gynecologist with complaints of pain with menses and intercourse. She has been unable to conceive for 3 years with her husband, who has a child with another woman. Pelvic examination is notable for nodularity of the uterosacral ligament and tender adnexal masses. What diagnostic modality is utilized to establish a definitive diagnosis in this patient? Topic Review Topic

1. CT scan
2. Laparoscopic examination with biopsy
3. MRI scan
4. Endometrial biopsy
5. Transvaginal ultrasound

PREFERRED RESPONSE ▶
TAG
(M2.GN.4769) A 32-year-old female presents to her primary care provider with pelvic pain. She reports that for the last several years, she has had chronic pain that is worst just before her menstrual period. Over the past two months, she has also had worsening pain during intercourse. She denies dysuria, vaginal discharge, or vaginal pruritus. The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed a year ago because it worsened her menorrhagia. She has now been using combined oral contraceptive pills (OCPs) for nearly a year. The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain. Her past medical history is otherwise unremarkable. Her temperature is 98.0°F (36.7°C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min. The patient has tenderness to palpation during vaginal exam with lateral displacement of the cervix. A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative.

Which of the following is the best next step in management? Topic Review Topic

1. Progesterone IUD
2. Pelvic MRI
3. Hysterosalpingogram
4. Hysteroscopy
5. Laparoscopy

PREFERRED RESPONSE ▶
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