QuestionSBA
QuestionChoice
This is unlikely to have a significant benefit over her current regime. The management of likely endometriosis aside from analgesia aims to reduce menstrual bleeding and induce amenorrhoea.
49843
b
Switch the co-codamol to codeine phosphate 60mg four times per day alongside paracetamol 1g four times per day
QuestionChoice
This woman likely has endometriosis, as evidenced by the cyclical pain. Contraceptives likely to induce amenorrhoea are likely to be most beneficial in the medical management. Medroxyprogesterone acetate is likely to induce amenorrhoea, with over 70% of users amenorrhoeic after a year of use.
49842
a
Medroxyprogesterone acetate (depo) injection
QuestionChoice
A copper intrauterine device can make menses heavier and more painful, therefore is not suitable for the management of dysmenorrhoea.
49846
e
Insertion of a copper intrauterine device
QuestionChoice
Mefenamic acid is a non-steroidal anti-inflammatory drug (NSAID). It should not be taken alongside other NSAIDs, e.g. ibuprofen.
49845
d
Advise the addition of mefenamic acid on the days when pain is worst
QuestionChoice
Whilst oophorectomy will induce menopause and therefore stop menstrual bleeding, surgical management of endometriosis is usually only considered where medical management has failed. In addition, it is not clear this woman's future fertility desires.
49844
c
Bilateral oophorectomy
QuestionComment
So I get the answer - but. what do we do with the COCP? Will she stay on it? do people go on both depo + COCP?
Patient.info suggests that we should either change the COCP formulation OR try a different contraception. so in this question would it be better for the option to say ''switch to depo'' instead? 
15499
QuestionComment
i agree, thats why i went for mefenamic acid as didnt know if she could be on two forms at the same time?

16030
User
subscriber
Gas Haemophilus
User
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DNA Tachycardia
QuestionComment
Is mefenamic acid more effective than ibuprofen for dysmenorrhoea? If ibuprofen has not been working for a pt's dysmenorrhoea, do we stop ibuprofen and prescribe mefenamic acid instead? Or do we move on to second-line management, such as COCP? 
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Chronic Nightshift
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Chapter
# Summary
  
Endometriosis is a condition characterised by the growth of endometrial tissue outside the uterine cavity. The principal symptoms include dysmenorrhoea, dyspareunia, and subfertility. Gold standard for diagnosis is a diagnostic laparoscopy, with treatment dependent on the severity of symptoms and ranging from analgesia and hormonal therapies to surgical intervention.
  
 
# Definition
  
 
Endometriosis is a gynaecological condition where endometrial tissue, which typically lines the uterus, proliferates outside the uterine cavity.
  
 
# Epidemiology
  
 
Although the exact prevalence is unknown due to often asymptomatic or non-specific presentation, endometriosis is estimated to affect approximately 10% of women in their reproductive years.
  
 
# Aetiology
  
 
The exact cause of endometriosis is unclear, but several theories exist including retrograde menstruation, coelomic metaplasia, and lymphatic or vascular dissemination of endometrial cells.
  
 
# Signs and Symptoms
  
 
Patients with endometriosis often present with the following symptoms:
  
 
  - Dysmenorrhoea
  - Dyspareunia
  - Subfertility
  - Dyschezia or haematochezia (uncommon), if colorectal tract is affected
  - On pelvic examination, tender, nodular masses (endometriomas) may be palpable on the ovaries or the ligaments surrounding the uterus. 
  - Fixed-retroverted uterus on examination 
  
 
# Differential Diagnosis
  
 
The primary differentials for endometriosis include other causes of dysmenorrhoea:
  
 
  - **Primary dysmenorrhoea:** characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.
  - **Uterine conditions** (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort. Would be visible on TV USS and/or MRI. 
  - **Adhesions:** pelvic pain and possible bowel obstruction. Usually seen in women who have had previous pelvic surgery or PID. 
  - **Pelvic inflammatory disease (PID):** presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.
  
 
# Investigations
  
 
The following diagnostic tools are commonly used in the diagnosis of endometriosis:

**Bedside:**

- Bimanual examination: fixed, retroverted uterus; may feel endometriomas (small masses) 
 
**No blood tests** are specifically indicated for endometriosis. 


**Imaging:**

- Transvaginal ultrasound: Often normal, but may identify an ovarian endometrioma, a cyst made of endometrial tissue in the ovary.
- MRI: Greater sensitivity than TV USS. 


**Invasive:**

  - Diagnostic laparoscopy: Considered the gold standard diagnostic tool, but it carries a small risk of complications (e.g. bowel perforation) and is not the first-line investigation. The procedure may be used for diagnosis and treatment in one go. 
  
 
# Management
  
 
Management strategies for endometriosis are predominantly symptom-based and range from medication to surgical interventions:

**Medical:**
 
  - Analgesia: Paracetamol or non-steroidal anti-inflammatory drugs
  - Hormonal therapies: Combined oral contraceptive pill, medroxyprogesterone acetate, gonadotrophin-releasing hormone agonists
  
**Surgical:**

  - Ablation or excision of lesions
  - Ovarian cystectomy (for endometriomas)
  - Bilateral oophorectomy (sometimes with a hysterectomy)
  
 
In cases where endometriosis is causing infertility, menstrual suppression would be unsuitable, and so ablation or excision of lesions (surgery) is more appropriate.
  
 
# Complications

- Infertility: Possible complication of excision of endometrioma from ovary, or as a result of the endometriomas themselves. 
- Adhesion formation: Complication of surgery. 
- Epithelial cell ovarian cancer: Women with endometriosis have twice as high a chance of developing this malignancy. 
 
# NICE Guidelines
  
 
  [Click here for NICE CKS on endometriosis](https://cks.nice.org.uk/topics/endometriosis/)
  
# References
  [BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/355/history-exam)
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10005
A 28-year-old woman attends her general practitioner with painful periods. She describes a 7-year history of pain in her lower abdomen and back alongside her period each month. She was commenced on the combined oral contraceptive pill (COCP) six months ago and advised to take this using an extended regime, having a withdrawal bleed once every three months.

She is having trouble with breakthrough bleeding with the COCP, and is still experiencing significant pain. She is taking ibuprofen 400mg three times daily, co-codamol 30/500 two tablets four times per day, and often requires time off work due to the intensity of the pain.

What is the most appropriate next step in the management of this patient?
a