What is Endometriosis?
n Chronic condition.
n Characterized by the growth of endometrial tissue in other sites outside the endometrial cavity.
¨ Pelvic cavity
¨ Ovaries
¨ Uterosacral ligaments
¨ Pouch of Douglas


 
What are the symptoms?
n Dysmenorrhea - recurrent painful periods
n Dyspareunia - painful intercourse
n Chronic lower abdominal and back pain
n Non-cyclic or cyclic pelvic pain
n Adnexal masses
n Subfertility

n Symptoms range from severe to minimal to no symptoms at all.


How common is endometriosis?
n Incidence is 40-60% in women with dysmenorrhea.
¨ And 20-30% in women with subfertility.

n Most common age of diagnosis is 40.


What are the causes of endometriosis?

n Retrograde menstruation
¨ Postulated in the early 1920s by Dr Sampson.
¨ Many women experience retrograde menstruation but do not go on to develop endometriosis.
¨ This theory also fails to explain why endometriosis can be found in remote areas such as the lungs, breasts, lymph nodes and even the eyes.

n The transplantation theory
¨ That endometriosis spreads via the circulatory and lymphatic system.

n Coelomic Metaplasia -
¨ This theory holds that certain cells, when stimulated, can transform themselves into a different kind of cells. 
n The hereditary theory
¨ Women with family members who have endometriosis are more likely, or are susceptible to developing the disease.
n Environmental factors
¨ A great deal of research is clearly highlighting that women who are exposed to environmental toxins are at much greater risk of developing Endometriosis along with other serious health disorders.


How do you diagnose endometriosis?
n Accurate history
¨ Dysmenorrhea, pelvic pain etc.
n Physical exam
¨ Tenderness in the posterior fornix or adnexal masses
n Laparoscopy is the only diagnostic test that can reliably rule out endometriosis.
¨ Gold standard.

When do you perform laparoscopy?
n Severe pain over several months.
n Pain requiring systemic therapy.
n Pain resulting in days off from work or school.
n Pain requiring admission to the hospital.


What are the medical treatment options?
n Oral contraceptives
n Progestins
n Androgenic agents
n GnRH analogues
¨ All suppress ovarian activity and menses and cause atrophy of the endometriotic implants.
n Base decision of treatment on side effect profile.

n Endometriomas are not amenable to medical treatment.
¨ Randomized controlled trials that compare excision or drainage and ablation of endometriomas >3 cm reported recurrence rates reduced and improved spontaneous pregnancy rates.


What does surgical management entail?
n Laparoscopy or open procedures.
n Requires excision or ablation (by laser or cautery) of the implants.
n Surgical excision of endometriosis results in improved pain relief and improved quality of life after 6 months compared with diagnostic laparoscopy alone.

How often does endometriosis recur after surgery?
n Rate of recurrence is ~20% after 5 years.

What are the unanswered questions?
n Is medical or surgical management more effective?
n Does long term medical management reduce the recurrence of endometriosis?
n What is the benefit of surgery for rectovaginal disease?

Screening for Cervical Cancer

 

Disorders of the Menstrual Cycle
• Amenorrhea
• Dysmenorrhea
• Premenstrual Syndrome




 Definitions
• Menorrhagia: heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days.
• Hypomenorrhea: periods with unusually light flow, often associated with hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndrome
• Metrorrhagia: irregular menstrual bleeding or bleeding between periods
• Menometrorrhagia: metrorrhagia associated with > 80 mL
• Polymenorrhea: frequent menstrual bleeding. Strictly, menses occur q 21 d or less
• Oligomenorrhea: Menses are > 35 d apart. Most commonly caused by PCOS, pregnancy, and anovulation

Differential Diagnosis
• Structural
– Cervical or vaginal laceration
– Uterine or cervical polyp
– Uterine leiomyoma
– Adenomyosis
– Cervical stenosis/Asherman’s (hypomenorrhea)
• Hormonal
– Anovulatory bleeding
– Hypogonadotropic hypogonadism
– Pregnancy
– Hormonal Contraception (i.e. OCPs, Depo-Provera)
• Malignancy
– Uterine or Cervical cancer
– Endometrial hyperplasia (potentially pre-malignant)
• Bleeding disorders
– von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet disorders


Workup

• History
– Timing of bleeding, quantity of bleeding, menstrual hx including menarche and recent periods, associated sxs, family hx of bleeding disorders

• Physical
– R/o vaginal or cervical source of bleeding. Bimanual may reveal bulky uterus/discrete fibroids
– Assess for obesity, hirsutism, stigmata of thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea)
– Pap smear
– Endometrial biopsy, if appropriate

• Pregnancy Test

• Imaging
– Pelvic ultrasound
– Sonohystogram or hysterosalpingogram

• Surgical
– Hysteroscopy
– D & C


Normal Ovulatory Cycle
• Follicular development à ovulation (d14) à corpus luteal function à luteolysis
• Endometrium is exposed to:
– ovarian production of estrogen à
(proliferation)
– Combination of estrogen and progesterone à
(secretory phase)
– Estrogen and progesterone withdrawal
(desquamation and repair)


Anovulatory Bleeding
• Corpus luteum is not produced
– Ovary fails to secrete progesterone, although estrogen production continues
– Result is continuous, unopposed E stimulation of endometrium:
• endometrial proliferation without P-induced differentiation / stabilization
– Endometrium becomes excessively vascular without stromal support à fragility and irregular endometrial bleeding


Etiologies
• Hyperandrogenic anovulation (PCOS, CAH, androgen-producing tumors)
• Hypothalamic dysfunction (stress, anorexia, exercise)
• Hyperprolactinemia
• Hypothyroidism
• Primary pituitary disease
• Premature ovarian failure
• Iatrogenic (secondary to radiation or chemo)

Anovulatory Bleeding: Adolescents (13-18 years)
• Anovulatory bleeding may be normal physiologic process, with ovulatory cycles not established until 1-2 yrs after menarche (immature HPG axis)
• Screen for coagulation disorders (PT/PTT, plts)
• May be caused by leukemia, ITP, hypersplenism
• Consider endometrial bx in adolescents with 2-3 year history of untreated anovulatory bleeding, especially if obese


Anovulatory Bleeding: Management in Adolescents
• High dose estrogen therapy for acute bleeding episodes (promotes rapid endometrial growth to cover denuded endometrial surfaces): conjugated equine estrogens PO up to 10 mg/d in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs
• Treat pts with blood dyscrasias for their specific diseases, r/o leukemia
• Prevent recurrent anovulatory bleeding with:
• cyclic progestogen (i.e. Provera)
or
• low dose (≤ 35 μg ethinyl estradiol) oral contraceptive
– suppresses ovarian and adrenal androgen production and increases SHBG à decreasing bioavailable androgens

Anovulatory Bleeding: Reproductive Age (19-39 years)
• Anovulatory bleeding not considered physiologic, evaluation required
• 6-10% of women have hyperandrogenic chronic anovulation (i.e. PCOS), characterized by noncyclic bleeding, hirsutism, obesity (BMI ≥ 25)
– Underlying biochemical abnormalities: noncyclic estrogen production, elevated serum testosterone, hypersecretion of LH, hyperinsulinemia.
– h/o rapidly progressing hirsutism with virilizationà suggests tumor
• Lab testing: HCG, TSH, fasting serum prolactin
– If androgen-producing tumor is suspected, serum DHEAS and testosterone levels
– If POF suspected, serum FSH
• Chronic anovulation resulting from hypothalamic dysfunction (dx’d by low FSH level) may be due to excessive psychologic stress, exercise, or weight loss


Anovulatory Bleeding:
Reproductive Age (19-39 yrs)
When is endometrial evaluation indicated?
• Sharp increase in incidence of endometrial CA from 2.3/100,000 ages 30-34 yrs à 6.1/100,000 ages 35-39 yrs
• Therefore, endometrial bx to exclude CA is indicated in any woman > 35 yrs old with suspected anovulatory bleeding
• Pts 19-35 who don’t respond to medical therapy or have prolonged periods of unopposed estrogen 2/2 anovulation merit endometrial bx


Anovulatory Bleeding: Reproductive Age (19-39 yrs)
Medical therapies
• Can be treated safely with either cyclic progestogen or OCPs, similar to adolescents.
• Estrogen-containing OCPs
– relatively contraindicated in women with HTN or DM
– contraindicated for women > 35 who smoke or have h/o thromboembolic dz
• If pregnancy is desired, ovulation induction with clomid is initial tx of choice
– Can induce withdrawal bleed with progestogen (i.e. provera), followed by initiation of therapy with Clomid, 50 mg/d for 5 days, starting b/t days 3 and 5 of menstrual cycle


Anovulatory Bleeding: 
Later Reproductive Age (40-Menopause)
• Incidence of anovulatory bleeding increases toward end of reproductive years
• In perimenopausal women, onset of anovulatory cycles is due to declining ovarian function.
• Can initiate hormone therapy for cycle control
When is endometrial evaluation indicated?
• Incidence of endometrial CA in women 40-49 years: 36.2/100,000
• All women > 40 yrs who present with suspected anovulatory bleeding merit endometrial bx after excluding pregnancy

Medical therapy
• Cyclic progestogen, low-dose OCPs, or cyclic HRT are all options
• Women with hot flashes secondary to decreased estrogen production can have symptomatic relief with ERT in combination with continuous or cyclic progestogen


Surgical therapy
• Surgical options include: hysterectomy and endometrial ablation
• Surgical tx only indicated when medical mgmt has failed and childbearing complete
• Some studies suggest hysterectomy may have higher long-term satisfaction than ablation
• Endometrial ablation: NovaSure, thermal balloon
– YAG laser and rollerball less widely-used currently
– 45% of women achieve amenorrhea after YAG laser or resectoscope. 12 month post-op satisfaction is 90%. Only 15% of women achieve amenorrhea after thermal balloon ablation, and 1 yr satisfaction rate still 90%
– Long-term satisfaction with ablation may be lower:
• in 3-year f/u study, 8.5% of women who had undergone ablation were re-ablated, an additional 8.5% had hyst
• In a 5-year follow up study, 34% of women who underwent ablation later had a hyst.