8/14/2019 Talkingwomen

1/1

8 tkgom clinicalreview

Endometriosis explained

THE 10th World Congress on

Endometriosis took place inMelbourne in March, with morethan 1000 delegates attendingfrom all over the world.

clinical PreSenTaTiOnEndometriosis is thought tooccur in 10% of women but theprevalence may be lower.

A study using data from theUK General Practice ResearchDatabase showed the specificsymptoms of dysmenorrhoea,menorrhagia and abdominal andpelvic pain were significantlyassociated with endometriosis.

In the year prior to diagnosis,

about 10 per cent of the womenhad multiple visits to their doc-tors to seek help and were twiceas likely to take time off workbecause of the symptoms.

There is a greater risk ofbeing misdiagnosed with irri-table bowel syndrome or pel-vic inflammatory disease, or of

these conditions co-existing.

A study to establish the typ-ical menstrual experience ofteenagers using the MenstrualDisorders of Teenagers question-naire was undertaken, including1051 women aged 16-18 yearsin the ACT.

About 70% felt their periodswere normal, but 25% had sig-nificant menstrual disturbanceincluding severe pain, schoolabsence, concern about theirpersonal menstrual experienceand visits to the GP.

DiaGnOSiS

The mean time from onsetof symptoms to diagnosis ofendometriosis is seven to 12years and even longer if theendometriosis has infiltrated intodeep tissues such as the uterosac-ral ligaments, bowel, bladder,ureter or rectovaginal septum.

The diagnosis of endometrio-

sis by investigations other thanlaparoscopy is not available.

Ultrasound transvaginal andrectal may have a limited place

in diagnosis of endometriomasand deep infiltrative disease.

At the congress, many stud-ies were presented that were

investigating markers that couldpossibly be developed as a lessinvasive test for endometriosis.

Inflammatory markers includ-ing macrophages, cytokines,growth factors and prostaglan-dins are being studied.

Sensory C nerve fibres havebeen shown to occur in the

endometrium of

women with endo-metriosis confir-med on laparos-copy but not inthe endometriumof women with-out endometriosis.This may becomea way of diagnos-ing endometrio-sis or targetingwhich women tolaparoscope.

ManaGeMenTThere is debate

about the use ofempirical treat-ment to suppressovulation as first-line managementrather than oper-ative laparoscopywith excision.

Suppressingovulation reduces endometrialtissue growth and may be con-sidered first-line in young teen-age women.

Various therapies have been

prescribed for ovarian suppres-sion, including the combined oral

contraceptive pill continuously,

long-acting progestins such asImplanon, and the Mirena IUD.

When symptoms persistdespite suppression of ovulation,operative laparoscopy with exci-sion would be appropriate as asecond-line treatment.

Operative laparoscopy withexcision and/or diathermy of

endometriotic plaques is themost widely used treatment.

cOnclUSiOnEndometriosis is a heterogenousdisorder. Symptoms may rangefrom minimal to none, throughto severe and crippling.

The degree of disease variesand is classified according to itsclinical staging at laparoscopy.

Especially in women in theirteenage years, endometriosis mayappear differently. The endome-triotic plaques visible at laparos-copy may appear as clear areasrather than the classical darkbrown or red implants.

There is concern about youngwomen undergoing multiple sur-gical, mainly laparoscopic, pro-cedures with excision of tissueand its consequence on long-term fertility.

The Jean Hailes Foundation forWomens Health is a national,

non-profit health organisation

focusing on clinical care,

innovative research and

practical education opportunities

for health professionals

and women.

D ezbthF

MBBS,

FRANZCOG,

FRCOG

Director, the Jean Hailes

Foundation for Womens

Health, President of the Asia

Pacific Menopause Federation

for the triennium 2007-10,

and President-Elect of the

Australasian Menopause

Society.

Photolibrary

Recommendations for GPs

1. Dysmenorrhoea, menorrhagia and

abdominopelvic pain in a woman of any age

who regularly has to take time off school or

work, leading to visits to her doctor, should be

investigated for endometriosis.

2. The time taken to diagnose endometriosis istoo long in most cases. The condition should be

part of the differential diagnosis of any woman,

regardless of age, presenting with the complex

of menstrual symptoms, including menstrual

pain, which impede normal function.

3. Laparoscopy remains the gold standard for

diagnosis of endometriosis.

4. Management remains controversial. In young

teenage women, an initial trial of ovarian

suppression may be appropriate.

5. Endometriosis is chronic and long-term

follow-up is necessary. Post-operative ovariansuppression may be necessary.

6. When symptoms persist, refer to either

a specialist endometriosis clinic or a

gynaecologist with advanced skills in

laparoscopic surgery or a special interest in

endometriosis management.