Makindo Medical Notes

Laparoscopy is the gold standard diagnostic test for endometriosis, based on the Royal College of Obstetrician and Gynaecologists guidelines. Subfertility may result from pelvic anatomical distortion due to adhesions, endometriomas, or disruption of reproductive processes.

About

• Endometrial-like tissue located outside the uterus, primarily in the pelvis but occasionally in distal sites.

Aetiology

• Potential factors include:
  • Ectopic tissue reflex and implantation.
  • Vascular/lymphatic spread and transformation of tissues in regions such as the vagina, cervix, bladder, lungs, and brain.
• Most deposits are found in the pelvis, and endometriosis is estrogen-dependent, responding to menstrual hormonal changes.

Clinical Presentation

• Typically affects women aged 30–40, uncommon in women under 20.
• Many with endometriosis remain asymptomatic.
• Possible symptoms:
  • Pelvic pain, dysmenorrhea (painful periods), dyspareunia (painful intercourse).
  • Heavy menstrual bleeding, infertility, haemoptysis, epistaxis, bowel and bladder symptoms.
  • Pelvic tenderness, though examination findings may be normal.

Investigations

• Lab tests: FBC, U&E, LFTs, pregnancy test if applicable.
• Culture any discharge.
• Imaging: Transvaginal ultrasound scan (USS).
• Key diagnostic tool: Laparoscopy for confirmation, requiring referral to a Gynaecologist.

Primary Care Management

• Referral to a Gynaecologist for confirmation via laparoscopy and treatment consideration.
• Analgesia for pain:
  • NSAIDs (e.g., ibuprofen, naproxen) or paracetamol if NSAIDs are contraindicated.
• Hormonal contraception for non-conception management:
  • 3-6 month trial of monophasic combined oral contraceptives, switching to continuous use if needed.
  • Alternative hormonal methods include oral progestogens, depot injections, subdermal implants, or intrauterine devices.
• Follow-up: Review after 3-6 months, or sooner if symptoms persist. Refer to Gynaecology if symptoms are unresponsive to primary care treatments.

Secondary Care Management

• Specialist hormonal therapies:
  • GnRH analogues to induce anovulation and amenorrhea, potentially with add-back HRT to mitigate menopausal symptoms and bone density loss.
• HRT options: Tibolone or combined progestogen plus estrogen, chosen by a specialist, especially following hysterectomy or oophorectomy.
• Surgical options:
  • Laparoscopic excision (diathermy, laser ablation) at initial diagnostic laparoscopy.
  • Radical surgery (hysterectomy and salpingo-oophorectomy) for completed families if other treatments fail.

References

• NICE Guidance on Endometriosis (2014)