Endometriosis Case Study

Endometriosis Case Study:

ME is a 32 yo G0P0 LMP two weeks ago who presents with a complaint of painful menses which has progressively worsened over the last 6 months to a year.  She also has spotting for 1-2 days after she ends her menses.  The pain is present with sexual intercourse and occasionally with bowel movements.   On physical exam, the uterus is normal in size, but tender to palpation.  She also has tender nodularity of her uterosacral ligaments.  A urine pregnancy test is negative.

o        This is a typical presentation of endometriosis

§         Ectopic endometrial tissue commonly found on peritoneal surface of pelvis – especially on the ovaries

§         60% of cases will have at least one ovary involved

§         This tissue cycles with the menstrual cycle like normal menstrual tissue

§         Very common occurrence

·         Often seen in patients with “type A personality” though this may be a result of a selection bias as they are the patient more likely to complain and seek therapy

·         Commonly begins in mid 20s progresses and worsens in their 30s and starts to improve in the 40s

§         Won’t occur in a post menopausal female due to regression of the tissue

·         Not seen in autopsy of elderly patient

§         #1 gynecological diagnosis of all admissions of women of child bearing age!!

§         The most pathognomonic finding but not the most common symptom is utero-sacral nodularity

·         Felt during the bimanual exam at the posterior cul-de-sac near the utero-sacral ligament where nodularity is due to the presence of these implants, very exquisitely painful for patient

·         Endometrial implants leave characteristic lesions known as “powder burn lesions”

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 Symptoms/Signs

o        Pain! – the overwhelming symptom that a patient will complain of

§         Contrasted from leiomyomas that present with abnormal bleeding

§         Classic Triad:

·         Dysmenorrhea – pain with the period

·         Dyspareunia – pain with sex

·         Dyschezia – pain with bowel movement

o        Common for endometriosis to be in cul-de-sac causing fibrosis of rectum to posterior vagina leading to dyschezia

o        Infertility

§         10% of all couples are infertile and about 40% of these are due to endometriosis

o        abnormal bleeding

·         Diagnosis of Endometriosis

o        Basically based on history à classic triad

o        Physical Exam à utero-sacral nodularity

o        Histologic

§         THE GOLD STANDARD!!

·         Laparoscopy and biopsy

·         Must see BOTH glands AND stroma

·         This is a point she said comes up a lot on USMLE exams!!

§         The truth is we are doing less laparoscopy to diagnose endometriosis due to large scale studies done with two groups of women one who had this invasive procedure and another with a presumptive diagnosis and treated them accordingly

·         Outcomes were identical!!

·         Therefore common practice is to just go with presumptive diagnosis and avoid the surgical procedure and corresponding morbidities

·         Treatment of Endometriosis

o        Medical

§         Analgesics

§         Hormonal Therapy

·         OCTs

·         Progestins à stop bleeding

·         Danazol à Testosterone derivative

·         GnRH agonist

·         Mifepristone

o        Surgical

§         Conservative

·         Solely removing the endometriotic implants

·         Peritoneal stripping, burning them off, or excision

·         Won’t get rid of underlying problem

§         Definitive

·         Total abdominal hysterectomy: uterus, ovaries, cervix and their tubes

o        Removes the cause of the endometriosis

o        Removal of the source of E = ovaries

o        Removal of uterus since it probably has some endometriosis

o        These patients universally do well unless endometriosis has spread to other places

o        This surgery is done on women in their 20s and 30s

·         Endometriosis can occur ANYWHERE!

o        Worse case she saw was endometriosis in the lungs causing the patient to require a chest tube in the ICU

o        You also see them in C-section scars and in vertical scars on skin so you can get it after surgery to remove it.

·         RECAP:

o        Fibroids à overwhelming symptom is abnormal bleeding

o        Endometriosis à overwhelming pain!

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