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Justin W. Ng Sinco
Diagnosis
Treatment of Symptoms
Case
Presentation
E.L., 30 year-old Gravida 1 Para 1 (1001) who
came in with a chief complaint of hypogastric
pain.
E.L., 30 y.o.
Gravida 1 Para 1 (1001)
Born on July 28, 1984 in Manila
Living in Camarin, Caloocan
Works as a Telecommunication specialist
Married
History of Present
Illness
Menarche at 13 years old
Subsequent menses were regular
28 32 days interval
3 5 days duration
Moderate flow, 4 pads per day
(+) Dysmenorrhea
History of Present
Illness
5 years PTC
Severe cyclic hypogastric pain
Worsened after menstruation
History of Present
Illness
5 years PTC
Consult at private OB
History of Present
Illness
3 years PTC
Danazol 200 mg 1 tab BID for 30 days (2012)
Injectable DMPA injected every three months
until November 2013
1 year PTC
Menstruation resumed regular cycle (May
2014)
History of Present
Illness
History of Present
Illness
5 days PTC
Transvaginal Ultrasound
Anteverted, normal-sized uterus with proliferative
endometrium (0.6 cm)
Right ovary is converted to a unilocular cyst with
low to medium level echoes measuring 3.2x2.5x2cm
Left ovary is converted to a unilocular cyst with
low to medium level echoes measuring 2.8x2.6x2cm
Cervix is unremarkable
Family History
Father, 58 years old, hypertensive and
with bronchial asthma
Mother, 66 years old, apparently well
Siblings: 2 siblings, with one sibling with
hypertension, high cholesterol, and
asthma
She denies other heredofamilial diseases
such as diabetes mellitus, malignancy,
liver, kidney and lung disease.
Gynecologic History
Menarche at 13 years old
Subsequent menses were regular
28 32 days interval
3 5 days duration
Moderate flow, 4 pads per day
(+) Dysmenorrhea, (+) Dyspareunia
(-) Post-coital bleeding, (-) Leukorrhea
Pap smear (2011) normal
Obstetrical History
Gravida 1 Para 1 (1001)
Delivered on 2007, term living girl, BW
3000g, appropriate for gestational age, via
NSD at Bernardino Hospital; no fetomaternal
complications
Method of
Contraception
OCP (2010 to 2013)
DMPA (2013)
Sexual History
Coitarche: 22 years old
1 sexual partner
Partner had 2 sexual partners
In a monogamous relationship
Review of Systems
Unremarkable
Physical Examination
General Survey: Patient is conscious,
coherent, not in cardiorespiratory distress,
with the following vital signs:
BP: 100/70 PR: 74 bpm
RR: 20 cpm
Temperature: 36.8 C
HEENT: Anicteric sclera, pink palpebral
conjunctivae, no nasoaural discharge, no
tonsillopharyngeal congestion, stye on right
lower lid
Neck: Supple neck, no neck vein
engorgement, no cervical lymphadenopathy
Physical Examination
Chest: Symmetrical chest expansion, no
retractions, no lagging
Lungs: Vesicular breath sounds, no
crackles, no wheezes.
Heart: Adynamic precordium, normal
rate, regular rhythm, no murmurs
Breast: Symmetrical contour, no
dimpling, no palpable mass, no
tenderness, no abnormal nipple discharge
Physical Examination
Abdomen: Flabby, soft, non-tender, normoactive
bowel sounds, no mass
Speculum exam: clean looking cervix with
minimal whitish discharge
Internal exam: normal looking external
genitalia, parous introitous, vagina admits two
fingers with ease, cervix firm and closed,
unenlarged uterus, no adnexal mass nor
tenderness
Extremities: No gross deformities, full and equal
pulses, no edema, no cyanosis
Skin: No active dermatoses
Dysmenorrhea
Primary
No pelvic pathology
Spasmodic
Secondary
Congestive
Differential Diagnoses
Severe hypogastric pain
(Dysmenorrhea)
Endometriosis
Ectopic pregnancy
Pelvic Inflammatory Disease
Abortion
Endometriosis
Presence of endometrial-like tissue outside the
uterus, which induces a chronic, inflammatory
reaction (Kennedy, et al., 2005) ESHRE Guidelines
2013
Endometriosis
Chronic pain
Infertility
Diminished QOL
Prevalence:
2 10% of general female
population
Up to 50% in infertile women
Endometriosis, Etiology
Retrograde menstruation
Metaplastic conversion of coelomic
epithelium
Anatomic, Hematogenous or Lymphatic
dissemination
Immunologic dysfunction
Genetics
Metaplasia
Dissemination
Pathophysiolog
y
Diaphragm
Peritoneu
m
Posterior
fornix
Lungs
Progesterone
Estrogen
Cytokines
Prostaglandins
Neovascularization
Fibrosis
PAIN
INFERTILITY
Diagnosis
History
Physical Examination
Medical Technology
Dysmenorrhea
Deep dyspareunia
Infertility
Non-gynecologic
Dyschezia
Dysuria
Hematuria
Rectal bleeding
Shoulder pain
Physical Examination
Speculum examination
Bimanual palpation
Rectovaginal palpation
Abdomen & Pelvis
Physical Examination
Induration and/or
nodules of the
rectovaginal wall,
or visible vaginal
nodules in the
posterior vaginal
fornix : Deep
endometriosis
Physical Examination
Adnexal mass: Ovarian endometrioma
Normal clinical examination does not rule
out disease
Medical Technology
Laparoscopy with histopathology:
Gold standard
Histology (Ovarian
endometrioma/Deep
infilitrating disease)
to rule-out
malignancy
Laparoscopy
Transvaginal ultrasonography
3D sonography
MRI
Biomarkers
Transvaginal ultrasound
Ground glass echogenicity and 1 to 4
compartments and no papillary structures
with detectable blood flow
Ovarian
Endometrioma
From http://www.ultrasound-images.com/
Transvaginal
ultrasound, E.L.
Right ovary is converted to a unilocular
cyst with low to medium level echoes
measuring 3.2x2.5x2cm
Left ovary is converted to a unilocular
cyst with low to medium level echoes
measuring 2.8x2.6x2cm
Additional Imaging
If with suspicion of deep endometriosis:
Bowel : Barium enema, Transvaginal or
Transrectal UTZ
Bladder : Transvaginal UTZ with full
bladder, Cystoscopy
Ureter : MRI, CT Urogram
Sensitive > Specific
Treatment Goals
Relief of pain
Fertility, if wanted
Admitting
Diagnosis
Gravida 1 Para 1 (1001)
Secondary dysmenorrhea probably secondary to
bilateral endometriotic cysts
Pain Management
Counselling plus
Analgesics
Combined hormonal contraceptives
Progestagens
Surgery
Hormonal Therapies
Hormonal
contraceptives
Progestagens
Anti-progestogens
GnRH agonist
Patient preference
Side effects
Efficacy
Cost
Availability
Hormonal
Contraceptives
Dyspareunia
Dysmenorrhea
Non-menstrual pain
Chronic pelvic pain
Combined hormonal
contraceptive
Combined oral
contraceptive pills
Vaginal contraceptive
ring or Transdermal
patch
GnRH agonists
Nafarelin
Leuprolide
Buserelin
Goserelin
Triptorelin
Hormonal
add-back
therapy
Aromatase Inhibitors
For rectovaginal endometriosis refractory
to other medical or surgical treatment
Aromatase
Inhibitor
OCP
Progestagen
GnRH agonist
Analgesics
NSAIDs or other analgesics may be given
Discuss risks
Gastric ulceration
Inhibition of ovulation
Cardiovascular disease
Surgery
1. Operative laparoscopy
Ablation vs. Excision
Equal effectiveness
3. Ovarian endometrioma
Cystectomy vs. Drainage & Coagulation
CO2 Laser Vaporization
Surgery
4. Deep Endometriosis
Surgical removal
Referral to centre of expertise
5. Hysterectomy
Hysterectomy + oophorectomy + removal of
endometrial lesions
Women with completed family; failed to
respond to conservative treatments
6. Adhesion Prevention
Oxidized regenerated cellulose
Other anti-adhesion agents
Pre-operative hormonal
treatment
Alleviates symptoms before the surgery
No change in outcome of surgery
Post-operative
hormonal treatment
Short-term vs. Long-term
Long-term therapy
Secondary prevention:
Prevent recurrence of pain symptoms
Prevent recurrence of disease
Extragenital
Endometriosis
Surgical removal
Medical treatment
Non-medical strategies
Supplements and alternative medicine
are not recommended.
Plan
Patient is for Laparoscopic bilateral
oophorocystectomy with chromopertubation
Plan
For Laparoscopic bilateral
oophorocystectomy with
chromopertubation
NPO 6 hours prior to OR
IVF once on NPO: 1L D5LR for 8 hours
For Blood typing
Give Cefuroxime 1.5 g TIV (-) ANST 1
hour prior to OR
Laboratory Results
Blood type: A+
Histopathologic report of the bilateral
ovarian cysts: results pending
Laboratory Results
CBC
Hgb 150
Hct 0.43
Platelet count 351
WBC 9.5 (0.65,0.23,0.67,0.04)
Urinalysis
Yellow/Hazy/6.0/1.015/Neg/Neg/1-2/0-2
Laboratory Results
FBS 5.8
BUN 3.85
Crea 64.7
SGPT 19.7
SGOT 13.8
Na 139
K 4.4
Ca 1.10
Laboratory Results
CXR: Normal
ECG: Sinus rhythm
Operation Technique
Ovarian epithelium covering the cysts
were excised; edges of the cyst were
stripped from the normal ovarian tissue.
Intra-operative findings
No ascites. Liver, spleen, subdiaphragmatic
surface and bowel were smooth
Uterine corpus was retroverted with smooth,
pinkish serosa. Posterior cul-de-sac has
multiple endometriotic implants.
Left ovary was cystically enlarged to 5x5cm
with a unilocular cyst measuring 3x2cm
exuding chocolate-brown fluid
Right ovary was likewise enlarged to 4x3cm
with a 1 cm cystic mass exuding
chocolate-brown fluid
Intra-operative findings
Both fallopian tubes were grossly normal
with egress of methylene blue on
chromopertubation. The rest of the
abdomino-pelvic organs are grossly
normal
Post-operative
Diagnosis
Gravida 1 Para 1 (1001)
Pelvic endometriosis AFS Stage III with bilateral
endometrioma
Treatment of Infertility
Medical
Surgical
Medical adjunct to surgery
Alternative treatments
Hormonal therapy
Not effective
Surgery
Operative laparoscopy + adhesiolysis
CO2 Laser vaporization vs. Monopolar
electrocoagulation
Excision of endometrioma capsule
Counselling
Non-medical strategies
Supplements and alternative medicine
are not recommended.
Assisted reproduction
Intrauterine insemination with controlled
ovarian stimulation within 6 months after
surgical treatment
Assisted reproductive technology
(IVS/ICSI) is recommended
GnRH agonist for 3 to 6 months prior
Menopause &
Endometriosis
Estrogen/Progestagen therapy or
Tibolone reduces menopausal symptoms
in surgically-induced menopause
Given at least up to the age of natural
menopause
Asymptomatic
Endometriosis
Incidental findings of ectopic foci with no
pelvic pain or infertility.
Surgical excision and ablation are not
recommended
Prevention of
Endometriosis
Etiology is unknown, thus primary
prevention is uncertain
Oral contraceptives : uncertain
Exercise : uncertain