L13 Endometriosis + Polycystic ovary syndrome

Endometriosis is defined as the presence of endometrial [blank_start]glands and stroma[blank_end] 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. • [blank_start]Implant[blank_end] theory: tissue travels via retrograde menstruation or surgery/deliveries • [blank_start]Lymphatic/vascular[blank_end] theory: explains distant location • [blank_start]Metaplasia[blank_end] theory: undifferentiated cells transform into endometrial tissue

Signs and symptoms of endometriosis: Common - • Dysmenorrhea – painful [blank_start]menstrual cramps[blank_end] • Pelvic pain • Dyspareunia – pain during [blank_start]sexual intercourse[blank_end] • Sub-fertility/[blank_start]Infertility[blank_end] • Pelvic mass Uncommon - • Dyschezia - painful [blank_start]bowel movements[blank_end], particularly during menstruation • Dysuria – painful [blank_start]urination[blank_end]

Which of these is not an endometriosis complication?

Investigative options for endo include: • Ultrasound – usually [blank_start]transvaginal[blank_end] • Laparoscopy – definitive diagnosis – direct [blank_start]visualisation[blank_end] with biopsyconfirmed endometrial glands or stroma outside of uterine cavity

Classification of Endometriosis: Stages I through IV, based on visual inspection during [blank_start]laparoscopy[blank_end]: • The appearance, [blank_start]size[blank_end], and depth of peritoneal and ovarian [blank_start]implants[blank_end] • The presence, extent, and type of [blank_start]lesions[blank_end] (red, red-pink and clear, white, peritoneal defects and black) • Presence, extent, and type of pelvic [blank_start]adhesions[blank_end] (ovaries and tubes) and the degree of [blank_start]cul-de-sac[blank_end] obliteration.

Laparoscopy is not required prior to medical management. Overall risk of any complication with laparoscopy, minor or major, is ~[blank_start]9[blank_end]%. • Injury to bowel, bladder, major blood vessel • Risk of [blank_start]bleeding[blank_end] or infection • Risk of anaesthetic Treatment options depend on whether [blank_start]fertility[blank_end] is desired. Medical management is based on [blank_start]hormonal[blank_end] suppression of endometriotic lesions. Oral contraceptives are considered [blank_start]first[blank_end] line treatment and patients get significant relief of dysmenorrhea within [blank_start]4[blank_end] months. Progestins in any form can be used, cons are loss of bone [blank_start]mineral[blank_end] density, • prolonged delay in resumption of [blank_start]menses/ovulation[blank_end], and breakthrough bleeding. Mirena, a progesterone IUD results in amenorrhea in [blank_start]60[blank_end]% of patients(good). Other options: - Danazol. Weak [blank_start]androgen[blank_end] capable of suppressing gonadotropin secretion, leading to [blank_start]amenorrhea[blank_end]. Bad side effects: weight [blank_start]gain[blank_end], acne, hirsutism, breast [blank_start]atrophy[blank_end], virilization, impact on lipids. - Gonadotrophin-releasing hormone (GnRH) agonists. 2 subsidized in NZ, [blank_start]goserelin acetate[blank_end] (implant) and [blank_start]leuprorelin[blank_end] (injection). For women who do not respond to oral contraceptives or progestins. Induces [blank_start]hypoestrogenism[blank_end] which causes menopausal symptoms. Cannot be used [blank_start]long[blank_end]-term (> 6 months) without hormone add-back therapy .

Surgical management: 1. Conservative • Laparoscopy to excise or ablate all [blank_start]visible[blank_end] lesions • Preserves fertility 2. Definitive • Total abdominal [blank_start]hysterectomy[blank_end] + bilateral salpingo-[blank_start]oophorectomy[blank_end] • Lose fertility • Early menopause

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

PCOS is the most common endocrine disorder among reproductive aged women and is largely genetic.

PCOS: Aetiology • Neuroendocrine derangement: Increased [blank_start]LH[blank_end] relative to [blank_start]FSH[blank_end] • Hyperinsulinemia: defect in [blank_start]insulin[blank_end] action or secretion • [blank_start]Androgen[blank_end] excess: ovarian and adrenal

Clinical presentation – signs and symptoms of PCOS 1. Infertility - [blank_start]70[blank_end]% affected 2. Menstrual [blank_start]disturbance[blank_end] - 60-70% affected 3. Hyper[blank_start]androgenism[blank_end] (hirsutism 70%, acne 30%, alopecia 10%) 4. Obesity, particularly [blank_start]truncal[blank_end] - 35-50% affected 5. Asymptomatic - [blank_start]22-33[blank_end]%

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

Which of these conditions is NOT a possible explanation for polycystic ovaries without PCOS?

Which of these is NOT a PCOS comorbidity?

Clomiphene citrate is considered first line treatment for infertility in PCOS.