Okay, so today we're going to be talking about endometriosis.

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Let's go ahead and get started with endometriosis.

So endometriosis, it's a pretty hyotopic.

There's a decent amount to know.

I do have a knemonic that's going to kind of help you remember most of the points that you need to know.

So let's go ahead and get started endometriosis.

What is endometriosis, Well, endometriosis is a condition where endometrio tissue, glands, and stroma are occurring outside of the uterine cavity, so quick refresher.

The uterus is a hollow muscular organ located in the pelvis between the bladder and the rectum.

There's a number of functions related to reproduction, menses, implantation, gestation, labor and delivery, etc.

We have the wall of the uterus, which has three layers.

We have the perimetrium or sorosa, which is the thin outer layer that envelops the uterus.

We have the myometrium, which is composed of smooth muscle cells.

And then the layer we're concerned with today, which is the endometrium, the inner mucosal layer that lines the inside of the uterus, and the layer that responds to cyclic ovarian hormone changes, thickening and sloughing off each month during menstruation.

So now that we know what endometrial tissue is and where it's supposed to be located, which is inside of the uterus, now let's talk about endometriosis, where endometril tissue is found outside of the uterus.

So in endometriosis, those endometrial cells they get bored.

They want to travel see the world, or at least the rest of the body.

So now we have these ectopic endometrial cells that are implanting themselves in random places throughout the body.

And because those ectopic endometrial cells have the same programming as the one inside of the uterus, they undergo the same cyclic changes each month, which causes inflammation, scarring, adhesions, bleeding, and a number of other problems will go over shortly.

So again, endometriosis, it's endometrial tissue occurring outside of the uter in cavity.

It seems like such a simple thing to commit to memory, but when you're taking your exam, you have a million other things to memorize and a million other diseases and all this stuff in your head, you might forget that.

So what's an easy way to remember that?

So I want you to remember endo meat tree osis, endo meat treosis, meat as in steak and tree like a tree with branches and leaves.

So when you see the word endometriosis, think endo meat treosis.

And I want you to picture this ridiculous picture of a meat tree, literally a tree with meat hanging from its branches.

And when you think of this ridiculous tree, I want you to think of exactly what you would think of in real life, which is, why is there meat hanging from this tree?

That's not where meat is supposed to be found.

And then you'll remember that's exactly what endometriosis is, meat or tissue where it's not supposed to be found.

So remember endo meat triosis, meat hanging from a tree not where it's supposed to be found, and then you'll remember that's endometriosis, which is endometrial tissue where it's not supposed to be found outside of the uterin cavity.

So where can we find these adventurous ac topic endometrial cells.

Well, all over the body really, the bowel, the bladder, posterior broad ligaments, even the diaphragm, and plural cavity up in the lungs.

The lesions typically though, will be found within the pelvis.

And the most common sights specifically of endometriosis, and the one you need to know for the exam, that's the ovaries.

Ovaries are the most common sight for endometriosis, so you have to remember that.

Now, why does this happen?

Why are these endometrial cells being found outside of their home base.

Well, we're not one hundred percent certain, and there's many proposed theories, but no single theory explains all of the cases we see in patients.

But we know it's likely multifactorial.

So a lot of different things contributing to the cause of this disease, genetic factors, altered immunity and balanced cell proliferation and apoptosis.

And while there's many proposed theories for the development of endometriosis, there's only one I'm going to mention because it's the current most accepted theory, and that's the theory of retrograde menstruation or Samson's theory of retrograde menstruation, named after doctor SAMs.

So the thought is during menstruation in some women, rather than endometrial cells flowing forward out of the body as intended, endometrial cells are actually flowing backwards through the fallopian tubes and into the peritoneal cavity during mensis, which can result in endometrial cells implanting themselves in different areas where they ain't supposed to be.

Sounds really simple, but the problem with this theory is that we've come to realize that retrograde menstruation it's actually really common.

Around ninety percent of women have retrograde menstruation, but only around ten percent of women are actually developing endometriosis.

So while this may be a contributing factor, we know there's other factors that are involved that make some women susceptible and others not.

So for the patho here because of the fact we're still not one hundred percent sure of the exact cause.

I don't think you need to memorize anything here for your exam, but it's always good to have a bit more info.

All right.

Next, let's talk about risk factors.

So who is going to be at a higher risk for endometriosis.

So that's going to be women with family history, no repair, so women having no previous berths, early menarchy, heavy menstrual bleeding, women who've had a history of obstruction of menstrual outflow, so in things such as cervical stenosis, among other factors.

Okay, let's move on to clinical manifestations.

It's very important to know how this presents.

So patients with endometriosis are found to have increased production of pain and inflammatory mediators.

These ectopic and dumetrial cells have the same estrogen receptors as endometril tissue found within the uterus, so they'll undergo the same cyclic changes causing inflammation, pain, bleeding, etc.

And where the patient will have pain all depends on the location of the ectopic endometrial tissue.

With that being said, let's talk about the most common presenting symptoms and how you'll likely see it on your exam.

So, a major component of endometriosis is pain.

Abdominal pelvic pain is quite common.

This can be described as dull, throbbing, sharp, or burning dysmennerrhia or painful menstruations can be very so vere in some women.

Dysperunia, which is pain with sexual intercourse.

This is more suggestive of peritoneal lesions or deep endometriosis lesions, dyskesia, which is difficulty or pain with defecation.

You'll see this in women with bowel endometriosis.

These women may also complain of diarrhea, constipation, or bowel cramping, heavy menstrual bleeding, infertility.

We're not exactly sure why endometriosis causes infertility, but it's believed to be related to the chronic inflammation associated with his condition.

This inflammation is believed to impair ovarian and endometrial function.

It can be damaging to sperm, and more advanced disease can lead to adhesions and distortion of pelvic anatomy, all of which can negatively impact the patient's ability to get pregnant.

So there's a number of other possible symptoms, urinary frequency, urgency, painful mike duration, Some patients may have chest pain, homoptosis, and some patients may even be asymptomatic.

So there's a number of clinical manifestations.

But if we're going by what's most common, what you'll likely be tested on, and what I was tested on.

It's really four things you need to know.

That's dysmneria, disperonia, dyskesia, and infertility.

They will almost certainly give you a patient in the reproductive years having trouble getting pregnant, complaining of severe pain with mensis, pain with defecation, and intercourse.

So how can you remember that?

Well, whenever you see endometriosis, I want you to think of furry men eating cheesy pears.

Furry men eating cheesy pears.

It's a very weird picture to paint in your head.

That's why you'll remember it.

Furry's going to help you remember infertility.

Men helps you remember DYSMNERIEA cheesy helps you remember diskesia or this cheesy as I used to pronounce it, and pair helps you remember disperunia.

Think back to your metri now, just think of some cheesy paars hanging off those branches with these furry men picking them off to eat them.

So remember furry men eating cheesy paars.

You can just think of these men with like big beards and they're eating these pears with just like nacho cheese.

Dripping off of them.

That's your clinical manifestations, and then I'll help you remember how it's going to present.

Next, let's talk about physical exam.

So physical exam is going to be different for each paine depending on the location and the size of the lesions.

And some women may actually have a completely normal physical exam, which in no way rules out the disease.

But if a patient does have positive physical exam findings, what should you be looking for?

So that's going to be focal tenderness on vaginal exam, nodules in the posterior formix at nexticle masses at nexticle mass if you're not familiar with the term, just means a mass of the ovary, fillopian tube or the surrounding area, immobility, fixed or lateral placement of the cervix or uterus.

Sometimes may also hear of the uterus being retroverted as well.

So these are just some general things to be aware of.

But again this isn't the highest yealed thing to know because many women may have a completely normal physical exam.

All right, let's talk about diagnosis next.

Now, the only way to definitively diagnose endometriosis is with a surgical biapsy going in cutting out some tissue sending it off to the lab.

This is obviously quite invasive, so the alternative to this is to make a clinical diagnosis, so a presumptive clinical diagnosis.

It's based on symptom signs and imaging findings.

So you have a patient who has the furry men eating cheesy paar symptoms, they may have some of the typical physical exam findings we went over.

Ultrasound can also be utilized and it's typically the first line modality when imaging is indicated, and what it may show is something known as an endometrioma, and endometrioma is a cystic mass arising from ectopic endometriol tissue.

Usually this is in the ovaries.

You'll sometimes here being referred to as a chocolate cyst because it contains thick, brown tar like fluid or old blood, so chocolate in appearance.

I suppose MRI is another imaging modality that may be utilized in some patients, although ultrasound is usually favored as it's cheaper, available at most facilities, and the sensitivity and specificity are similar between the two.

So those are the components of a clinical diagnosis signs, symptoms, and imaging findings, and a clinical diagnosis would be appropriate for a patient with mild to moderate symptoms, a patient who you're going to treat with lower risk meds like nsets hormonal contraceptives.

What I think you should remember for the exam is how to make your definitive diagnosis, because they love to ask on exam questions how are you going to make a definitive diagnosis for disease?

And the way you do that is as we went over before, and that's with a laparoscopy and biopsy, which involves a small incision, throwing some cameras in the abdomen, finding a suspicious lesion, setting it off for biopsy, and confirming it was indeed an endometril gland or stroma occurring outside of the uterine cavity.

Laparoscopy can serve as both a diagnostic and therapeutic tool, as when the lesions are visualized, they can also be removed, improving the pain for some women.

So this is obviously much more invasive than a clinical diagnosis, and it's going to be reserved for patients with more severe pain, patients who aren't responding to some of those first line meds will go over shortly as well as some other indications.

So again for diagnosis, you can make a clinical diagnosis based on signs, symptoms, and imaging findings.

Remember ultrasound if you do need imaging.

But if you want to make a definitive diagnosis, that's done surgically through laparoscopy.

And let's talk about treatment next.

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Now back to the show.

So a treatment of endometriosis related pain, we can manage this with medication or with surgery.

Let's start with the meds.

There's a few different classes and meds, hormonal contraceptives and says on rh analog stanazol.

There really isn't any compelling data to suggest one class over another based on efficacy, as they all have been found to have relatively similar clinical efficacy for reduction of pain.

So that being said, as efficacy is similar between the classes, your first line meds are going to be based more on cost, availability, side effect profile, etc.

So in women with mild to moderate pain, your first line treatment is generally going to be your combined estrogen progestin contraceptives.

These are going to be first line treatment for most women with endometriosis related pain.

Continuous regiments are found to be more effective at reducing pain than cyclic regiments, so it's best to take this continuously, so no hormone free intervals during the month.

So why do we start with this class if we don't have compelling data to suggest one class over another regarding efficacy.

But like I just talked about briefly before, it's because compared to other classes of meds, contraceptives are cheap, they're pretty well tolerated, and they can be used long term, whereas most of the other classes will go over generally do not possess these careacteristics.

So the combined contraceptives are thought to reduce pain and disease activity through suppression of ovariant function causing atrophy of endometrio tissue.

And of all of the treatments I'm going to go over for endometriosis, if you're going to remember just one, this would be the one I would say to focus on your birth control, your contraceptives, and if a woman is unable to take combined contraceptives, progestin only therapy is an alternative next end sets, So n sets are technically still suggested as one of the first line treatment options for endometriosis related pain.

This is from the a COG guidelines and up to date, and for some of the same reasons we use contraceptives.

They're low cost, readily available, so these will often be used in combination with contraceptives.

But the thing you need to keep in mind is there's not any high quality data to support their use.

We know they work well for other forms of pelvic pain.

They're effective for primary dysmentary but the data just is really lacking to prove their efficacy in endometriosis, but we still use them because of their low cost, etc.

Okay, next, let's talk about gener EH analogs.

This there's another important treatment options, your GnRH analogs, so your gonadotropin releasing hormone analogs GENERH analogs include your GnRH agonists like laproulide or your GnRH antagonists like elagolis.

These meds downregulate the pituitary ovarian axis, decreasing estrogen, which ultimately induces amenorrhea and endometrio atrophy, leading to improvement in pain.

Now, they're usually not first line, and it's not due to lack of efficacy, but more due to the fact that there's more side effects and limitations on long term use.

They can cause hypoestrogenic side effects like decreased libido, mood swings, headaches, decreased bone density.

So reduce these side effects, there's something called add back therapy.

This is where you add back hormones, usually progestin, and this improves some of the hypoestrogenic side effects.

So again this class is no less effective than our contraceptives, but due to more side effects as well as limitation with how long these meds can safely be used for six to twelve months.

Generally, they're usually second line meds and more reserved for patients with severe symptoms or patients refractory to your first line agents.

Next, we have danozol.

It's an androgenic drug that works really well.

The problem is the side effect profile of danazol is not so good acne edema, weight gain, hersaitism, voice deepening, milegas, so it's often not used due to this.

So those are the main meds to remember.

Obviously, remember your contraceptives, that's the big one, and said's GnRH analogues and then danozol.

Those are the ones that I would focus on again really focusing in on your contraceptives.

Let's talk about surgery next.

So surgery is obviously more invasive, more expensive, can be associated with complications, so surgery is usually going to be reserved for patients who have tried and failed medications, patients with contraindications to meds, patients with obstructions of the urinary or GI tract, and there's two main options for surgery.

You have your conservative approach and then your more definitive invasive approach, which is with a hysterectomy.

Let's start with a conservative approach first, and that's with a laparoscopic excision and or ablation.

Now, this is usually first line surgical option because this procedure preserves fertility and hormone production.

It's less invasive than a hysterectomy, so this is usually where you'll start with your surgical options.

So the same laparoscopy we discussed before being used as a diagnostic tool to make a definitive diagnosis.

Well, as I talked about before, it can be therapeutic when they go in and they're obtaining tissue for biopsy.

They can also remove the suspicious lesions to improve the patient's symptoms.

The problem is, while there is typically significant pain relief after the procedure, pain recurrence is fairly common.

So in women with debilitating symptoms, who have no plans for future childbearing, and who have failed both medical therapy and conservative surgical therapy, these women would be candidates for a hysterectomy with or without upherrectomy.

This is obviously last line treatment as it's more invasive and obviously due to the loss of fertility with this type of surgery, but it can be a definitive option for some patients.

So just a quick bit of info on the with or without upherrectomy part.

If you're doing to hys direct me anyways, you're removing the uterus, why not just remove the ovaries in all women, which would likely increase the efficacy of the surgery.

While in premenopausal women, once you remove the ovaries, menopause begins, so you induce premature menopause, meaning all of the symptoms and risks associated with menopause begin.

So if this was an older woman that's close to menopause anyways, hys directed me with upherrectomy may be appropriate.

Or if a woman has extensive disease involving the ovaries, whufherrectomy also would be appropriate, but this is obviously going to be a case by case basis depending on the patient involved.

So that's endometriosis.

There's a lot to know.

Let's do a thirty second recap of the highlights.

Then let's talk about a mnemonic to help you remember the highest yield points.

So endometriosis what is it endometrio tissue occurring outside of the uterus?

Where is it most commonly found the ovaries?

How is your patient going to present furree men eating cheesy pears?

How do you definitively diagnose cut it out in biopsy?

What's your first line?

MAD usually going to be contraceptives can often be combined with en seids.

Surgery is going to be reserved for severe or refractory cases.

Now, what about the mnemonic?

Well, back to the meat tree we talked about before endometriosis.

So most of the HyG old points about endometriosis are in and around that meat tree.

So every time you hear endo meat triosis, I want you to think of that meat tree we talked about before, a tree with meat hanging from its branches.

As remember that's not where meat is supposed to be found, which will help you remember what endometriosis is meat or tissue, endometro tissue specifically where it's not supposed to be found.

Now, next to that met tree, there's some furry men hanging out and they're snacking on some cheesy pears they pulled off the tree.

That helps remember the common clinical manifestations you'll likely find in the vignette, which is infertility, furry dys men area, men, dyskesia or dyschiesia, cheesy and dispair Unia pairs next on the trunk of the tree, like any cartoon tree you've ever seen before, there's always that little oval hole in the trunk with a bird or squirrel hanging out in it.

So on our tree, on the trunk there's a small oval opening and oval helps you remember ovaries are the most common area to be affected.

And then there's a bird hanging out in that hole to help you remember birth control bird aka contraceptives, which is the first line meds bird birth control.

So endometriosis meet hanging from a tree, bunch of furry men around the tree eating cheesy pears, oval hole at the trunk of the tree with a bird hanging out in it, and that's endometriosis.

Let's do a few quick questions to test your knowledge.

Question one, a thirty two year old Nola, Paris woman complains of dysmenorrhea that has become progressively worse over the past few years.

She also reports experiencing difficult, painful defecation, diskesia and painful sexual intercourse dysperonia.

The patient and her partner have been trying unsuccessfully to conceive for the last year.

She has tried over the counter end sets for pain relief, but does not find them to be very effective.

Upon pelvic examination, focal tenderness and immobility of the uterus is noted.

A presumptive clinical diagnose of endometriosis is made.

Her primary goal is pain management, as she is not planning to conceive at this time.

In the absence of contraindications, which of the following medications would be the most appropriate option to try next?

A combined contraceptive b g nrh agonist, C danizol or d g nrh antagonist.

So again, which of the following medications would be most appropriate to try next?

And that is going to be a combined contraceptive.

So we have a classic presentation for endometriosis.

We have a patient with dysmenorrhea and fertility dyskesia and dysperunia.

So the furry men eating cheesy pair symptoms we went over earlier.

On physical exam, you have focal tenderness, a fixed uterus.

We see she's tried N sets with minimal pain relief, so which medication class would be most appropriate to try next?

Well, right off the bat, we can eliminate danozol as we discussed before, it has a lot of side effects and will not be a first line men so we're left with contraceptives and a GnRH analog.

While they both have similar efficacy, we know we usually start with contraceptives due to the more favorable side effect profile and the ability to use these medications long term compared to GENERH analogs, which are generally limited to six to twelve months and also require adback therapy to combat the hypoestrogenic side effects.

So again, that is going to be a combined contraceptives.

Question two, in order to establish a definitive diagnosis for the patient described above, which of the following diagnostic procedures would be the most appropriate choice?

A laparoscopy with biopsy, b ultrasound, cMRI, or DCT computed tomography.

So that is going to be a laparoscopy with biopsy.

So remember, the only way to definitively diagnose endometriosis is with tissue biopsy, which is typically obtained during laparoscopic surgery.

So locating and cutting out tissue and sending it off to the lab.

MRI and ultrasound can be used in the initial workup, but will not provide a definitive diagnosis, and CT is generally not util in the diagnostic workup due to exposure of ionizing radiation to the patient as well as low test sensitivity.

Question three, A laparoscopy with biopsy is performed on the patient described above, confirming the diagnosis of endometriosis.

The provider informs the patient that the endometrio lesians found were located in the most common site for endometriosis.

What area of the body would the provider likely be referring to, So that is going to be the ovaries.

So the ovaries are the most common sight for endometriosis, seen in up to sixty seven percent of women with this condition.

Okay, so that was endometriosis.

I hope that was helpful.

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Thank you again for listening, and best of luck in school.