Define endometriosis

• endometrial looking-like tissue outside the uterus
• can form masses and cysts

Where can endometriosis be found?

• anterior or posterior cul-de-sac are the main sites
• ovaries, broad ligament, uterosacral ligament, rectumcolon, vagina, perineal area
• lungs, abdomen (can spread via lymphatics/vascular)

How often are malignant tumors found?

• 0.3-0.8% of cases

How common is endometriosis?

• in about 10-25% of women presenting with gynaecological symptoms
• found by diagnostic laparoscopy
• Prevalence is about 1%
• more common in infertile women, those with surcially removed ovaries and many are found in women with unexplained infertility

What are the symptoms of endometriosis?

• extremely variable!
• depends on site
• may be asymptomatic

Describe the three theories on the pathogenesis of endometriosis

• retrograde menstruation (where the blood flows up the tubes)
• Vascular and lymphatic spread
• metaplastic theory: metaplasia of pelvic eritoneum into endometrial tissue (metaplasia: change in the type of adult cells in a tissue to a form abnormal for that tissue)

How is endometriosis diagnosed?

• History: classic triad is dysmennorhea, dysparunia, dyschezia. Irregular bleeding and infertility
• Pelvic and abdominal exam
• Investigations: pelvic U/S looking for cysts (endometrial cysts usually can't be seen), MRI, laparoscopy, laparotomy, biopsy

What are the clinical findings associated with endometriosis?

• uncomfortable pelvic exam
• induration/tenderness in uterosacral ligaments or Pouch of Douglas by pelvic, rectal exam
• fixed retroverted, tender uterus & adnexa
• endometriosis of other organs
• often cyclic

What is the laprascopic appearance of endometriosis?

• black, bluish but initially red
• may show lesions
• adhesions, healed implants

Let's do a DDx for acute pelvic pain. Talk about the reproductive tract causes.

• Pregnancy related: abortion, ectopic
• Ovary: ruptured cyst, torsion of cyst, bleeding corpus luteum, Mittelschmerz
• Tubes: torsion or the tube or of a stump following sterilization
• Uterus: degeneration of a fibroid, torsion of a fibroid, pyometra (uterine infection), dysmenorrhoea, retrograde menstruation
• Acute PID

Let's do a DDx for acute pelvic pain. Describe non-reproductive system causes.

• GI: appendix, rupture, obstruction, IBD, mesenteric adenitis (lymph node inflammation), diverticulitis
• GU: acute UTI, renal calculi
• Vascular: nesenteric vascular disease, aortic aneurysm
• rectus haematoma, herpes zoster
• Metabolic: porphyria, sickle cell crisis

Let's do a DDx for chronic pelvic pain.

• Cyclic: Mittelschmerz (mid-cycle pain), 1 or 2ary dysmenorrhoea
• Acyclic: causes outside the repro tract, causes within the repro tract: ovarian tumors, endometriosis, pelvic adhesive disease, pelvic varicosities

There are surgical and medical options for treating endometriosis, outline the surgical options.

• Definitive: removal of area containing the endometriosis (ex; hysterectomy)
• Conservative: destruction/excision (electrocoagulation, laser, argon, beam)
• Pain control: LUNA (laprascopic uteralsacral nerve ablation), 70% pain control in 1 year. There's also PSN (presacral neurectomy). Hysterectomy if severe.

There are surgical and medical options for treating endometriosis, outline the medical options.

• Pain: NSAIDS, codeine based drugs
• induction of psudo-pregnancy state/ovarian supression with:
• pregestins (50 mg/day)
• OC (but does not treat adhesion and cyst formation, so not good for severe cases)
• GnRH agonist, cannot be used long term (only up to a year) because of side effects
• Danazol, a testosterone derivative with mechanism similar to GnRH (irriversible side effects)
• aromatase inhibitors (only controls pain). Promotes egg release
  

Define adenomyosis

• It's endometriosis in the myometrium
• occurs in 20-30% or uteruses
• if the lesion form a tumor-like nodule it's called an adenomyoma
• causes uterine thickenning

How does adenomyosis present?

• mostly asymptomatic
• abnormal uterine bleeding and dysmenorrhoea (the little "islands" release PGs and show inflammatory changes which causes pain) those "islands" may not participate in the normal cyclic changes
• uterus can be boggy & tender, but is generally symmetrically enlarged

How would you treat adenomyosis?

• NSAIDS, OCT, progesterone, IUD
• surgical: hysterectomy, endometrial ablation

Define Dysmenorrhea and describe it's pathophysiology

• Pain with menstrusation
• Prostaglandins PGF_2a and PGE₂ are higher in women with 1ary dysmennorhea.
• PG realeased due to endometrial cell lysis, increases myometrial []'ns, causes ischemia, increases uterine activity and sensitization of nerve terminals to PGs and endoperoxides (this causes an exacerbation of pain)

What are the clinical features of dysmenorrhoea?

• occurs usually in ovulatory cycles
• initial onset usually within 2 years of menarche
• begins just before first day, lasts 48-72 hours
• pain is cramp-like (NSAIDS work for this!), associated with nausea, vomiting, diarrhoea, lower backache & headache (NSAIDS don't work for this)
• pelvic exam is normal

How would you treat primary dysmennorhea?

• education
• medical: NSAIDS to ↓ PGs, OC, COX-2 inhibitors (cardio side effects!), Progestagens (↓ menses, ↓ovulation)
• smoking cessation
• When a combo of NSAIDS and ovulation suppression doesn't work, consider secondary and consider laparascopy, hysteroscopy, and pelvic U/S

Define secondary Dysmenorrhea

• pain during meses due to an underlying disease
• often not confined to menses (can be before or after)
• more often in older women, less related to first day of flow, often symptoms like infertility, dysparunia, abnormal uterine bleeding present.

Describe some causes of secondary dysmenorrhea

• endometriosis
• pelvic inflammation
• fibroid tumors, adenomyosis
• ovarian cysts
• pelvic congestion
• obstructive congenital, uterine, cervical and vaginal abnormalities

Define chronic pelvic pain

• Pelvic pain of > 6 months duration
• includes uterine and non-uterine pain that is primarily non-cyclic

Describe how pain is felt differently by visceral vs. somatic nerves.

• Somatic: skin, muscles, joints and parietal peritoneum
• Visceral: more diffusely spread due to viscera-somatic convergence and lack of a well defined projection area in the sensory cortex for its identification. It is usually referred to the skin, supplied by the corresponding spinal cord segment.

What innervates the perineun, vulva and lower vagina?

• S2-4
• Pudendal, inguinal, genitofemoral, posterfemoral cutaneous

What innervates upper vagina, cervix, lower uterine segment, posterior urethra, bladder trigone, uterosacral and cardinal ligaments, rect-sigmoid, lower ureters

• S2-4, pelvic parasympathetics

What innervates uterine fundus, proximal fallopial tubes, broad ligament, upper bladder, cecum, appendix, terminal large bowel

• T11 & 12, L1, sympathetic via hypogastric plexus

What innervates the ovaries?

• T9 & 10, sympathetic via renal & aortic plexus, celiac & mesenteric ganglia

What innervates the abdominal wall?

• T12-L1, iliohypogastric, ilioinguinal
• L1-2, genitofemoral

Describe investigations necessary for someone with chronic pelvic pain: history

• ChLORIDE FPP
• relationship to menstrual cycle, bowel movements, voiding, sex or exercise
• soley MSK or accomplanying visceral pain
• stress symptoms
• detailed gynecologic history

Describe investigations necessary for someone with chronic pelvic pain: physical exam, labs, imaging

• abdominal and pelvic exam
• Lab: only measures of infection are really helpful
• Imaging: endoscopy, abdominal/pelvic CT, pelvic U/S, diagnostic laparoscopy is gold standard

Describe the causes of chronic pelvic pain

• endometriosis
• chronic PID
• ovarian pain including ovarian remnant syndrome
• uterine pain: adenomyosis, uterine fibroids degeneratng or torting
  
• salpingo-oophoritis
• pelvic congestion syndrome: multiparous women who have pelvic varicosities, dilated veins
• GU pain: urinary retention, interstitial cystitis, COMMON, cyclic pain, adhesions
• GI pain: (innervation overlaps): GI neoplasms, IBS, partial bowel obstruction, IBD, diverticulitis, hernia formation
• neuromuscular pain
• psychological factors