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Endometriosis for Undergraduates

This article provides a historical perspective on endometriosis and discusses its symptoms, diagnosis methods, and management options. It also explores the two main theories regarding its cause and outlines the principles of medical and surgical treatment.

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Endometriosis for Undergraduates

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  1. Endometriosis for Undergraduates Max Brinsmead MB BS PhD November 2017

  2. Historical Perspective • 1970’s “A disease of uncertain aetiology whose relevance to fertility is uncertain” • 1980’s “A common condition that may be present in as many as one woman in four” • 1990’s Much more known about aetiology. Principles of management emerging. • 2000+ • Evidence-based management

  3. Endometriosis is: • Ectopic endometrium i.e. “internal menstruation” • Requires laparoscopy +/- biopsy for diagnosis • Activity is more important than appearance • Symptoms do not always correlate with grading

  4. Symptoms of Endometriosis • The Classic Triad… • Dysmenorrhoea • Sufficient to interfere with daily life • Dyspareunia • Deep pain during or after sexual intercourse • Infertility

  5. Symptoms of Endometriosis • But consider also… • Pre menstrual staining • Pain with defaecation during menstruation • Period-related urinary symptoms including haematuria • Intermenstrual chronic pelvic pain • Disordered cycles • Family history

  6. Diagnosis of Endometriosis • A Careful History (The most important) • Rule out other Causes of Symptoms (The next most important) • Examination (not much help) • Ultrasound (of little value) • MRI (useful for rectovaginal deposits) • Laparoscopy (The gold standard) • Serum CA125 (Lacks sensitivity) • Iridology (a good guess!)

  7. Differential Diagnosis: • Primary Dysmenorrhoea • Irritable Bowel Syndrome • Ovulation Pain • Pelvic Inflammatory Disease • Psychosexual Problems

  8. Aetiology • Two Main Theories: • Retrograde menstruation • Peritoneal metaplasia • Predisposing Factors • Familial predisposition • Disordered immunity • Environmental toxins • Recurrent ovulation • Infertile partner • Obstructed menstrual flow

  9. Principles of Management: • When the Problem is Pain – Use Medical Rx • When the Problem is Infertility – Use Surgical Rx • But it is a complex decision and individualisation of care is desirable • When there is no Problem – Use no Rx • Some patients require multidisciplinary care

  10. Medical Therapy Options • Progestins • COC (best in continuous form) • Provera or Norethisterone • The Mirena IUS • Danazol & Gestrinone • GnRH agonists +/- Add Back Therapy • A question of side effects

  11. Surgery for Endometriosis • Laparoscopy • Biopsy to confirm diagnosis is desirable • Ablate superficial deposits taking care near bowel, bladder and ureters. Use bipolar diathermy • There is evidence that excision may be marginally better • Endometrioma – must remove cyst wall. Conserve as much ovary as possible. • Extensive surgery with removal of entire pelvic peritoneum best done by advanced laparoscopic surgeon • Hysterectomy +/- oophorectomy. Excise all visible lesions. Warn about recurrence risk

  12. Any Questions or Comments? Please leave a note on the Welcome Page to this website

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