L13 Endometriosis + Polycystic ovary syndrome

Endometriosis is defined as the presence of endometrial ❌ outside the uterus.
Pathogenesis: Several theories have been proposed for the development and progression of endometriosis, yet no single one holds true for every patient or manifestation.
• ❌ theory: tissue travels via retrograde menstruation or surgery/deliveries
• ❌ theory: explains distant location
• ❌ theory: undifferentiated cells transform into endometrial tissue

Signs and symptoms of endometriosis:
Common -
• Dysmenorrhea – painful ❌
• Pelvic pain
• Dyspareunia – pain during ❌
• Sub-fertility/❌
• Pelvic mass
Uncommon -
• Dyschezia - painful ❌, particularly during menstruation
• Dysuria – painful ❌

Investigative options for endo include:
• Ultrasound – usually ❌
• Laparoscopy – definitive diagnosis – direct ❌ with biopsyconfirmed endometrial glands or stroma outside of uterine cavity

Classification of Endometriosis:
Stages I through IV, based on visual inspection during ❌:
• The appearance, ❌, and depth of peritoneal and ovarian ❌
• The presence, extent, and type of ❌ (red, red-pink and clear, white, peritoneal defects and black)
• Presence, extent, and type of pelvic ❌ (ovaries and tubes) and the degree of ❌ obliteration.

Laparoscopy is not required prior to medical management. Overall risk of any complication with laparoscopy, minor or major, is ~❌%.
• Injury to bowel, bladder, major blood vessel
• Risk of ❌ or infection
• Risk of anaesthetic
Treatment options depend on whether ❌ is desired. Medical management is based on ❌ suppression of
endometriotic lesions. Oral contraceptives are considered ❌ line treatment and patients get significant relief of dysmenorrhea within ❌ months. Progestins in any form can be used, cons are loss of bone ❌ density, • prolonged delay in resumption of ❌, and breakthrough bleeding. Mirena, a progesterone IUD results in amenorrhea in ❌% of patients(good).
Other options:
- Danazol. Weak ❌ capable of suppressing gonadotropin secretion, leading to ❌. Bad side effects: weight ❌, acne, hirsutism, breast ❌, virilization, impact on lipids.
- Gonadotrophin-releasing hormone (GnRH) agonists. 2 subsidized in NZ, ❌ (implant) and ❌ (injection). For women who do not respond to oral contraceptives or progestins. Induces ❌ which causes menopausal symptoms. Cannot be used ❌-term (> 6 months) without hormone add-back therapy .

Surgical management:
1. Conservative
• Laparoscopy to excise or ablate all ❌ lesions
• Preserves fertility
2. Definitive
• Total abdominal ❌ + bilateral salpingo-❌
• Lose fertility
• Early menopause

Polycystic Ovarian Syndrome (PCOS)
• Collection of signs and symptoms
• May be ❌ to diagnose
• Often ❌
• Heterogeneous presentation
• Features ❌ with age
• PCOS is a syndrome so NO single test or feature is diagnostic

PCOS: Aetiology
• Neuroendocrine derangement: Increased ❌ relative to ❌
• Hyperinsulinemia: defect in ❌ action or secretion
• ❌ excess: ovarian and adrenal

Clinical presentation – signs and symptoms of PCOS
1. Infertility - ❌% affected
2. Menstrual ❌ - 60-70% affected
3. Hyper❌ (hirsutism 70%, acne 30%, alopecia 10%)
4. Obesity, particularly ❌ - 35-50% affected
5. Asymptomatic - ❌%

PCOS diagnosis, ❌ of 3 criteria need to be met:
1. Hyperandrogenism
- Clinical (hirsutism, acne, frontal balding)
- Biochemical (high serum ❌ concentrations)
2. Menstrual ❌ – absent or infrequent periods
3. Polycystic ovaries
AND ❌ of other aetiologies (congenital adrenal hyperplasia, androgen-secreting tumours, Cushings syndrome)