Makindo Medical Notes

According to the Royal College of Obstetricians and Gynaecologists (RCOG), laparoscopy is the gold standard for diagnosing endometriosis. Subfertility in affected individuals may result from pelvic anatomical distortion caused by adhesions, endometriomas, or other disruptions to normal reproductive processes.

About

• Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus. Although it predominantly affects the pelvic region, it can occasionally appear in more distant sites.

Aetiology

• Possible contributing factors include:
  • Retrograde menstruation (reflux and implantation of endometrial tissue).
  • Vascular or lymphatic spread and transformation of tissue in locations such as the vagina, cervix, bladder, lungs, and brain.
• Most endometriotic deposits are found in the pelvis. Endometriosis is estrogen-dependent and responds to hormonal fluctuations during the menstrual cycle.

Clinical Presentation

• Usually affects women aged 30–40 and is less common in those under 20.
• Many women with endometriosis remain asymptomatic.
• Potential symptoms include:
  • Pelvic pain, dysmenorrhea (painful periods), and dyspareunia (painful intercourse).
  • Heavy menstrual bleeding, infertility, haemoptysis, epistaxis, and bowel or bladder symptoms.
  • Pelvic tenderness on examination, although findings may often be normal.

Investigations

• Laboratory tests: FBC, U&Es, LFTs, and pregnancy test if applicable.
• Obtain cultures if there is any discharge.
• Imaging: Transvaginal ultrasound scan (USS).
• Laparoscopy remains the definitive diagnostic tool, necessitating referral to a Gynaecologist for confirmation.

Primary Care Management

• Refer to a Gynaecologist for diagnostic laparoscopy and to discuss treatment options.
• Pain management:
  • Use NSAIDs (e.g., ibuprofen, naproxen) or paracetamol when NSAIDs are contraindicated.
• Hormonal contraception for patients not seeking conception:
  • A 3- to 6-month trial of a monophasic combined oral contraceptive pill; consider continuous use if necessary.
  • Other hormonal options include oral progestogens, depot injections, subdermal implants, or the intrauterine system (IUS).
• Follow-up: Review at 3–6 months (or sooner if symptoms persist). Refer back to Gynaecology if symptoms do not respond to primary care treatments.

Secondary Care Management

• Specialist hormonal therapies:
  • GnRH analogues to suppress ovarian function and induce amenorrhea, often combined with add-back HRT to alleviate menopausal symptoms and protect bone density.
• Hormone Replacement Therapy (HRT):
  • Tibolone or a combination of estrogen and progestogen, typically prescribed by a specialist, particularly after hysterectomy or oophorectomy.
• Surgical options:
  • Laparoscopic excision (via diathermy or laser ablation) performed during the diagnostic laparoscopy.
  • Radical surgery (hysterectomy with salpingo-oophorectomy) may be considered for women who have completed their families and have refractory symptoms.

References

• NICE Guidance on Endometriosis (2014)