Hospital Medicine

Endometriosis

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Endometriosis

I. What every physician needs to know.

Endometriosis occurs when endometrial glands and stroma are located outside the uterine cavity. The root cause of endometriosis remains unknown at this time. There are several prevailing theories. The most commonly accepted is the concept of "retrograde menstruation" with endometrial tissue traveling through the Fallopian tubes into the pelvis. Another theory is that the peritoneal cells are pleuriopotent and can transform themselves into endometrial tissue. The third theory is that the endometriosis spreads through the lymphatic or vascular system. Endometriosis is a chronic condition, which leads to chronic pain and infertility in up to 5-10% of reproductive age women.

II. Diagnostic Confirmation: Are you sure your patient has Endometriosis?

Diagnosis can only be truly confirmed by laparoscopy. However, if a patient complains of pain that worsens right before menses, is severe during menses and improves after menses is completed each month, they may be presumed to have endometriosis.

A. History Part I: Pattern Recognition:

Patient presents with severe abdomino-pelvic pain prior to and during menses and pain remits after menses have ended. A patient's bowel or bladder function may be affected. Patient may complain of pain with intercourse.

B. History Part 2: Prevalence:

Endometriosis affects up to 5-10% of menstruating women. Menstruating women of any age may be affected. Typically the disease is diagnosed in women in their 20's and 30's.

C. History Part 3: Competing diagnoses that can mimic Endometriosis.

Dysmenorrhea (the difference can only be confirmed by laparoscopy), irritable bowel syndrome (should occur in a less cyclical fashion than endometriosis), pain from adhesive disease from prior surgery or pelvic inflammatory disease (again should be less cyclic in nature), ovarian cysts (should be a more constant pain), adenomyosis (could potentially only be distinguished by laparoscopy), fibroids (would cause a more constant pain).

D. Physical Examination Findings.

Potentially could be none. Patient could have cervical motion tenderness. Patient may have pain on abdominal exam or on pelvic exam. If patient has an endometrioma (or ovarian cyst filled with endometriosis), she may have an enlarged ovary.

E. What diagnostic tests should be performed?

None

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

None

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

None if straightforward endometriosis is suspected. These patients are susceptible to endometriomas, so a pelvic ultrasound or pelvic magnetic resonance imaging (MRI) may be useful. Neither modality is effective in diagnosing straightforward endometriosis.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

None

III. Default Management.

1. Medical management

a. Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics

b. Hormonal therapy with continuous oral contraceptive pills, contraceptive ring, progesterone only pill, depo provera, depo lupron, or progesterone intrauterine device

2. Surgical management

A. Immediate management.

Pain management with NSAIDs and if not helpful, then with narcotics. Call for a gynecology consult.

B. Physical Examination Tips to Guide Management.

In the immediate period after diagnosis, the main goal is to get a patient's pain under control, so following the patient's pain scale will be the most valuable.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

None

D. Long-term management.

Patient will need to decide with her physician what type of hormonal therapy she should use to control pain with menses. If these work in combination with pain medication, she may not need any further therapy. If her pain is continuing despite medical therapy, she would be a candidate for laparoscopy.

E. Common Pitfalls and Side-Effects of Management.

Patients can become addicted to narcotics.

IV. Management with Co-Morbidities.

A. Renal Insufficiency.

NSAIDs may not be appropriate in all patients with renal insufficiency.

B. Liver Insufficiency.

Estrogen therapy may not be appropriate in all patients with liver insufficiency.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

Estrogen hormonal therapy may not be appropriate in all cases.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

Hormonal therapy may not always be acceptable with certain malignancies, such as estrogen receptor/progesterone receptor positive breast cancer.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

Watch the total amount of narcotics. Dosage should not be high enough to impede respiratory rate.

I. Gastrointestinal or Nutrition Issues.

No change in standard management.

J. Hematologic or Coagulation Issues.

If patient has history of deep vein thrombosis or pulmonary embolism, she would not be a candidate for estrogen containing hormone therapy.

K. Dementia or Psychiatric Illness/Treatment.

Narcotics could be harmful to the mental status of the patient.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

None

B. Anticipated Length of Stay.

1 to 2 days

C. When is the Patient Ready for Discharge.

When their pain has improved such that they can take oral pain medications at home to control their pain.

D. Arranging for Clinic Follow-up.

1-2 weeks in a gynecology office.

1. When should clinic follow up be arranged and with whom.

1-2 weeks in a gynecology office.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

A pelvic ultrasound if it was not completed in the hospital.

E. Placement Considerations.

None

F. Prognosis and Patient Counseling.

This is a chronic disease that will likely need continued intervention for a long period of time. The patient needs to follow up regularly with a gynecologist. The patient is at risk for infertility as endometriosis is often a progressive disease, so patients are advised to complete childbearing at an earlier age if at all possible.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

None

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Ensure that patient has enough pain medication to take until she has her follow up visit with the gynecologist and also ensure that her pain is adequately relieved by oral pain medications.

VII. What's the evidence?

Bulun, Serdar, E. "Endometriosis". New England Journal of Medicine. vol. 360. January 15, 2009. pp. 268-279.

"The American College of Obstetricians and Gynecologists Practice Bulletin, Management of Endometriosis". vol. Number 114. July 201.

John, Schorge. "Williams Gynecology". 2008. pp. 225-243.

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