Makindo Medical Notes

👩‍⚕️ According to the Royal College of Obstetricians and Gynaecologists (RCOG), laparoscopy is the gold standard for diagnosing endometriosis. ⚠️ Subfertility may result from adhesions, endometriomas, or pelvic anatomical distortion disrupting normal reproductive processes.

📖 About

• Endometriosis = endometrial-like tissue outside the uterus. Predominantly pelvic (ovaries, peritoneum, pouch of Douglas) but can rarely appear at distant sites (e.g. lungs, brain).
• Estrogen-dependent: symptoms often improve in pregnancy or post-menopause.

🧪 Aetiology

• Retrograde menstruation: endometrial tissue refluxes via fallopian tubes and implants in pelvis.
• Other theories: vascular/lymphatic spread, metaplasia of coelomic epithelium.
• Most deposits occur in the pelvis; lesions are hormonally sensitive and bleed cyclically.

⚡ Clinical Presentation

• Commonest in women aged 30–40; rare under 20.
• Symptoms vary — many women remain asymptomatic.
• Typical features:
  • Severe dysmenorrhoea (often progressive, starting pre-menstruation).
  • Dyspareunia (deep pelvic pain on intercourse).
  • Chronic pelvic pain ± heavy menstrual bleeding.
  • Subfertility (due to adhesions/distorted anatomy).
  • Extrapelvic symptoms (rare): cyclical haemoptysis, epistaxis, bowel/bladder symptoms.
• Exam: pelvic tenderness, fixed retroverted uterus, adnexal masses (endometriomas). Many have a normal exam.

🧪 Investigations

• Bloods: FBC, U&Es, LFTs, pregnancy test; cultures if discharge.
• Imaging: transvaginal ultrasound (endometriomas may be seen).
• Laparoscopy = gold standard (diagnostic + therapeutic).

💊 Primary Care Management

• 👩‍⚕️ Refer to Gynaecology for diagnostic laparoscopy.
• ⚡ Pain relief: NSAIDs (ibuprofen, naproxen); paracetamol if contraindicated.
• Hormonal suppression (if not seeking conception):
  • COCP trial (3–6 months, continuous if helpful).
  • Progestogens: oral, depot, implant, or LNG-IUS.
• 📅 Review at 3–6 months; if persistent, escalate to secondary care.

🏥 Secondary Care Management

• 💊 Specialist hormonal therapy:
  • GnRH analogues → induce reversible menopause. Use with “add-back” HRT to protect bone and manage menopausal symptoms.
• 🌸 HRT: Tibolone or estrogen + progestogen, especially post-hysterectomy/oophorectomy.
• 🔪 Surgical options:
  • Laparoscopic excision/ablation of deposits (often done at diagnostic laparoscopy).
  • Radical surgery (TAH + BSO) for refractory symptoms, usually when family complete.

🌟 Teaching Pearl

• Endometriosis is the leading cause of secondary dysmenorrhoea in women in their 30s.
• Always consider in women with cyclical pelvic pain not relieved by NSAIDs/COCP.

📚 References

• NICE Guidance on Endometriosis (2014)
• RCOG Green-top Guideline No. 24: Management of Endometriosis.