An Interview on Endometriosis

Educational Objectives

The goal of this program is to improve diagnosis and treatment of endometriosis. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the pathophysiology of endometriosis.

Summary

Diagnosis of endometriosis: probably affects 5% to 10% of women of reproductive age; prevalence uncertain because no accurate noninvasive diagnostic test available; women may have pain with intercourse or menses, or infertility; only laparoscopy 100% sensitive; magnetic resonance imaging and ultrasonography not sensitive; differential diagnosis includes dysmenorrhea, fibroids, ovarian cyst, constipation, irritable bowel syndrome, painful bladder syndrome, and musculoskeletal conditions; many women asymptomatic

Pathophysiology: endometrial cells found outside uterus; lesions commonly on ovaries, peritoneal lining, or bowel but may be seen throughout body

Etiology: retrograde menstruation may be cause of endometriosis, but backflow through fallopian tubes common in normal women; progenitor cells in peritoneum (coelomic epithelium) may give rise to endometrial and peritoneal cells, or conditions may permit transformation to endometrial cells; another theory holds that embryonic mullerian remnants differentiate and seed peritoneum

Pain: symptoms of endometriosis correlate with intensity of immune response to deposits of endometrium (women without endometriosis may have less inflammation and scarring in response to retrograde menstruation than those with endometriosis); development of pain probably related to nerve transmission thresholds and processing of pain in central nervous system

Signs and symptoms: overlap with those of other disorders; large ovarian endometrioma may present with torsion, pain, or bleeding; pain cyclic or chronic; lesions of bowel or bladder may cause hematuria, dysuria, constipation, or dyschezia; although other conditions should be ruled out, some disorders in differential diagnosis also difficult to diagnose (eg, irritable bowel syndrome, dysfunction of pelvic floor)

Outcomes: some women asymptomatic while others have strong inflammatory response with scarring; endometriosis may resolve spontaneously (20%-30% of women), remain unchanged (30%), or worsen (30%-40%)

Assessment: history — approach to woman with possible endometriosis depends on primary complaint (pain vs infertility); history should focus on nature of pain, relationship to menses, symptoms related to gastrointestinal (GI) or urinary tract, risk factors for infections, time course and location of pain, and exacerbating activities; examination — may reveal nodules or tenderness; endometriosis in vagina unusual; pelvic ultrasonography may rule out fibroids and adenomyosis, detect endometrioma or cyst, and identify involvement of bladder or GI tract

Management: pain — symptomatic treatment reasonable for mild to moderate pain; nonsteroidal anti-inflammatory drugs (NSAIDs) supported by minimal evidence but inexpensive and benefit some women; other options include combination oral contraceptives (taken in continuous fashion), depot medroxyprogesterone, and etonogestrel implant (Implanon, Nexplanon); laparoscopy appropriate for uncontrolled or severe pain; other treatments include gonadotropin-releasing hormone agonists such as leuprolide or groserelin; infertility — some cases of endometriosis discovered during evaluation for infertility; infertility in women with endometriosis may be caused by mechanical effects or reduction in quality of eggs related to inflammatory milieu in pelvis; such patients may benefit from laparoscopic lysis of adhesions and endometrial implants; refractory endometriosis — may be treated with hysterectomy plus salpingo-oophorectomy

Readings

Heublein S et al: Inducers of G-protein coupled estrogen receptor (GPER) in endometriosis: potential implications for macrophages and follicle maturation. J Reprod Immunol 2013 Mar;97(1):95-103; Králíčková M et al: Altered immunity in endometriosis: what came first? Immunol Invest 2018 Aug;47(6):569-82; Lee KH et al: Comparison of the efficacy of diegnogest and levonorgestrel-releasing intrauterine system after laparoscopic surgery for endometriosis. J Obstet Gynaecol Res 2018 Jul 5 [Epub ahead of print]; Reid S et al: To determine the optimal ultrasonographic screening method for rectal/rectosigmoid deep endometriosis: ultrasound “sliding sign”, transvaginal ultrasound direct visualization or both? Acta Obstet Gynecol Scand 2018 Jul 14 [Epub ahead of print]; Shafrir AL et al: Risk for and consequences of endometriosis: A critical epidemiologic review. Best Pract Res Clin Obstet Gynaecol 2018 Jul 3 [Epub ahead of print]; Taylor HS et al: An evidence-based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis. Int J Gynaecol Obstet 2018 Aug;142(2):131-42; Verket NJ et al: Health-related quality of life in women with endometriosis, compared to the general population and women with rheumatoid arthritis. Acta Obstet Gynecol Scand 2018 Jul 14 [Epub ahead of print].

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Heublein presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Heublein’s interview was recorded exclusively for Audio Digest. The Audio Digest Foundation thank the speakers for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB651901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.