WEBVTT 1 00:00:00.240 --> 00:00:03.600 Okay, so today we're going to be talking about endometriosis. Big thank you 2 00:00:03.640 --> 00:00:07.679 to everybody who's left a nice comment, everybody who's shared the podcast or YouTube 3 00:00:07.759 --> 00:00:11.039 channel with a friend or a classmate. I really appreciate it, so thank 4 00:00:11.080 --> 00:00:14.880 you so much. Let's go ahead and get started with endometriosis. So endometriosis, 5 00:00:14.919 --> 00:00:18.039 it's a pretty hyotopic. There's a decent amount to know. I do 6 00:00:18.079 --> 00:00:21.079 have a knemonic that's going to kind of help you remember most of the points 7 00:00:21.079 --> 00:00:24.440 that you need to know. So let's go ahead and get started endometriosis. 8 00:00:24.440 --> 00:00:30.320 What is endometriosis, Well, endometriosis is a condition where endometrio tissue, glands, 9 00:00:30.359 --> 00:00:34.799 and stroma are occurring outside of the uterine cavity, so quick refresher. 10 00:00:34.840 --> 00:00:39.359 The uterus is a hollow muscular organ located in the pelvis between the bladder and 11 00:00:39.399 --> 00:00:43.840 the rectum. There's a number of functions related to reproduction, menses, implantation, 12 00:00:43.960 --> 00:00:46.439 gestation, labor and delivery, etc. We have the wall of the 13 00:00:46.479 --> 00:00:50.399 uterus, which has three layers. We have the perimetrium or sorosa, which 14 00:00:50.439 --> 00:00:54.320 is the thin outer layer that envelops the uterus. We have the myometrium, 15 00:00:54.359 --> 00:00:58.159 which is composed of smooth muscle cells. And then the layer we're concerned with 16 00:00:58.240 --> 00:01:02.960 today, which is the endometrium, the inner mucosal layer that lines the inside 17 00:01:02.960 --> 00:01:07.000 of the uterus, and the layer that responds to cyclic ovarian hormone changes, 18 00:01:07.319 --> 00:01:11.000 thickening and sloughing off each month during menstruation. So now that we know what 19 00:01:11.159 --> 00:01:15.560 endometrial tissue is and where it's supposed to be located, which is inside of 20 00:01:15.599 --> 00:01:19.519 the uterus, now let's talk about endometriosis, where endometril tissue is found outside 21 00:01:19.560 --> 00:01:25.040 of the uterus. So in endometriosis, those endometrial cells they get bored. 22 00:01:25.079 --> 00:01:27.239 They want to travel see the world, or at least the rest of the 23 00:01:27.280 --> 00:01:33.599 body. So now we have these ectopic endometrial cells that are implanting themselves in 24 00:01:33.680 --> 00:01:38.040 random places throughout the body. And because those ectopic endometrial cells have the same 25 00:01:38.120 --> 00:01:42.480 programming as the one inside of the uterus, they undergo the same cyclic changes 26 00:01:42.519 --> 00:01:47.599 each month, which causes inflammation, scarring, adhesions, bleeding, and a 27 00:01:47.640 --> 00:01:51.480 number of other problems will go over shortly. So again, endometriosis, it's 28 00:01:51.599 --> 00:01:55.879 endometrial tissue occurring outside of the uter in cavity. It seems like such a 29 00:01:55.959 --> 00:01:59.159 simple thing to commit to memory, but when you're taking your exam, you 30 00:01:59.200 --> 00:02:02.159 have a million other things to memorize and a million other diseases and all this 31 00:02:02.159 --> 00:02:06.239 stuff in your head, you might forget that. So what's an easy way 32 00:02:06.239 --> 00:02:09.280 to remember that? So I want you to remember endo meat tree osis, 33 00:02:09.599 --> 00:02:15.520 endo meat treosis, meat as in steak and tree like a tree with branches 34 00:02:15.520 --> 00:02:19.800 and leaves. So when you see the word endometriosis, think endo meat treosis. 35 00:02:20.000 --> 00:02:23.680 And I want you to picture this ridiculous picture of a meat tree, 36 00:02:23.719 --> 00:02:27.719 literally a tree with meat hanging from its branches. And when you think of 37 00:02:27.759 --> 00:02:30.759 this ridiculous tree, I want you to think of exactly what you would think 38 00:02:30.759 --> 00:02:34.439 of in real life, which is, why is there meat hanging from this 39 00:02:34.560 --> 00:02:37.639 tree? That's not where meat is supposed to be found. And then you'll 40 00:02:37.639 --> 00:02:42.639 remember that's exactly what endometriosis is, meat or tissue where it's not supposed to 41 00:02:42.719 --> 00:02:46.919 be found. So remember endo meat triosis, meat hanging from a tree not 42 00:02:46.919 --> 00:02:51.240 where it's supposed to be found, and then you'll remember that's endometriosis, which 43 00:02:51.280 --> 00:02:55.120 is endometrial tissue where it's not supposed to be found outside of the uterin cavity. 44 00:02:55.240 --> 00:03:00.280 So where can we find these adventurous ac topic endometrial cells. Well, 45 00:03:00.319 --> 00:03:04.479 all over the body really, the bowel, the bladder, posterior broad ligaments, 46 00:03:04.639 --> 00:03:07.120 even the diaphragm, and plural cavity up in the lungs. The lesions 47 00:03:07.159 --> 00:03:10.840 typically though, will be found within the pelvis. And the most common sights 48 00:03:10.960 --> 00:03:15.520 specifically of endometriosis, and the one you need to know for the exam, 49 00:03:15.840 --> 00:03:19.960 that's the ovaries. Ovaries are the most common sight for endometriosis, so you 50 00:03:20.080 --> 00:03:23.039 have to remember that. Now, why does this happen? Why are these 51 00:03:23.159 --> 00:03:27.360 endometrial cells being found outside of their home base. Well, we're not one 52 00:03:27.439 --> 00:03:31.280 hundred percent certain, and there's many proposed theories, but no single theory explains 53 00:03:31.360 --> 00:03:37.240 all of the cases we see in patients. But we know it's likely multifactorial. 54 00:03:37.360 --> 00:03:39.400 So a lot of different things contributing to the cause of this disease, 55 00:03:39.680 --> 00:03:45.719 genetic factors, altered immunity and balanced cell proliferation and apoptosis. And while there's 56 00:03:45.800 --> 00:03:50.360 many proposed theories for the development of endometriosis, there's only one I'm going to 57 00:03:50.439 --> 00:03:54.360 mention because it's the current most accepted theory, and that's the theory of retrograde 58 00:03:54.400 --> 00:04:00.000 menstruation or Samson's theory of retrograde menstruation, named after doctor SAMs. So the 59 00:04:00.039 --> 00:04:05.680 thought is during menstruation in some women, rather than endometrial cells flowing forward out 60 00:04:05.719 --> 00:04:11.800 of the body as intended, endometrial cells are actually flowing backwards through the fallopian 61 00:04:11.840 --> 00:04:15.680 tubes and into the peritoneal cavity during mensis, which can result in endometrial cells 62 00:04:15.720 --> 00:04:20.480 implanting themselves in different areas where they ain't supposed to be. Sounds really simple, 63 00:04:20.480 --> 00:04:25.199 but the problem with this theory is that we've come to realize that retrograde 64 00:04:25.240 --> 00:04:30.600 menstruation it's actually really common. Around ninety percent of women have retrograde menstruation, 65 00:04:30.959 --> 00:04:34.160 but only around ten percent of women are actually developing endometriosis. So while this 66 00:04:34.319 --> 00:04:39.639 may be a contributing factor, we know there's other factors that are involved that 67 00:04:39.720 --> 00:04:43.600 make some women susceptible and others not. So for the patho here because of 68 00:04:43.639 --> 00:04:46.480 the fact we're still not one hundred percent sure of the exact cause. I 69 00:04:46.519 --> 00:04:48.680 don't think you need to memorize anything here for your exam, but it's always 70 00:04:48.720 --> 00:04:51.399 good to have a bit more info. All right. Next, let's talk 71 00:04:51.399 --> 00:04:55.720 about risk factors. So who is going to be at a higher risk for 72 00:04:55.839 --> 00:04:59.920 endometriosis. So that's going to be women with family history, no repair, 73 00:05:00.319 --> 00:05:04.079 so women having no previous berths, early menarchy, heavy menstrual bleeding, women 74 00:05:04.160 --> 00:05:09.839 who've had a history of obstruction of menstrual outflow, so in things such as 75 00:05:09.879 --> 00:05:14.639 cervical stenosis, among other factors. Okay, let's move on to clinical manifestations. 76 00:05:14.680 --> 00:05:18.040 It's very important to know how this presents. So patients with endometriosis are 77 00:05:18.120 --> 00:05:24.639 found to have increased production of pain and inflammatory mediators. These ectopic and dumetrial 78 00:05:24.680 --> 00:05:29.720 cells have the same estrogen receptors as endometril tissue found within the uterus, so 79 00:05:29.759 --> 00:05:33.240 they'll undergo the same cyclic changes causing inflammation, pain, bleeding, etc. 80 00:05:33.879 --> 00:05:38.839 And where the patient will have pain all depends on the location of the ectopic 81 00:05:38.959 --> 00:05:43.120 endometrial tissue. With that being said, let's talk about the most common presenting 82 00:05:43.160 --> 00:05:46.879 symptoms and how you'll likely see it on your exam. So, a major 83 00:05:46.920 --> 00:05:53.240 component of endometriosis is pain. Abdominal pelvic pain is quite common. This can 84 00:05:53.240 --> 00:05:59.000 be described as dull, throbbing, sharp, or burning dysmennerrhia or painful menstruations 85 00:05:59.079 --> 00:06:02.600 can be very so vere in some women. Dysperunia, which is pain with 86 00:06:02.639 --> 00:06:09.360 sexual intercourse. This is more suggestive of peritoneal lesions or deep endometriosis lesions, 87 00:06:09.480 --> 00:06:13.839 dyskesia, which is difficulty or pain with defecation. You'll see this in women 88 00:06:13.920 --> 00:06:17.439 with bowel endometriosis. These women may also complain of diarrhea, constipation, or 89 00:06:17.480 --> 00:06:23.759 bowel cramping, heavy menstrual bleeding, infertility. We're not exactly sure why endometriosis 90 00:06:23.839 --> 00:06:28.160 causes infertility, but it's believed to be related to the chronic inflammation associated with 91 00:06:28.199 --> 00:06:31.879 his condition. This inflammation is believed to impair ovarian and endometrial function. It 92 00:06:31.920 --> 00:06:35.600 can be damaging to sperm, and more advanced disease can lead to adhesions and 93 00:06:35.639 --> 00:06:40.800 distortion of pelvic anatomy, all of which can negatively impact the patient's ability to 94 00:06:40.800 --> 00:06:44.680 get pregnant. So there's a number of other possible symptoms, urinary frequency, 95 00:06:44.839 --> 00:06:47.639 urgency, painful mike duration, Some patients may have chest pain, homoptosis, 96 00:06:47.959 --> 00:06:53.279 and some patients may even be asymptomatic. So there's a number of clinical manifestations. 97 00:06:53.519 --> 00:06:57.279 But if we're going by what's most common, what you'll likely be tested 98 00:06:57.319 --> 00:07:00.360 on, and what I was tested on. It's really four things you need 99 00:07:00.399 --> 00:07:04.279 to know. That's dysmneria, disperonia, dyskesia, and infertility. They will 100 00:07:04.279 --> 00:07:09.439 almost certainly give you a patient in the reproductive years having trouble getting pregnant, 101 00:07:09.639 --> 00:07:14.160 complaining of severe pain with mensis, pain with defecation, and intercourse. So 102 00:07:14.199 --> 00:07:16.879 how can you remember that? Well, whenever you see endometriosis, I want 103 00:07:16.879 --> 00:07:21.639 you to think of furry men eating cheesy pears. Furry men eating cheesy pears. 104 00:07:21.639 --> 00:07:25.079 It's a very weird picture to paint in your head. That's why you'll 105 00:07:25.079 --> 00:07:29.399 remember it. Furry's going to help you remember infertility. Men helps you remember 106 00:07:29.480 --> 00:07:33.120 DYSMNERIEA cheesy helps you remember diskesia or this cheesy as I used to pronounce it, 107 00:07:33.160 --> 00:07:36.839 and pair helps you remember disperunia. Think back to your metri now, 108 00:07:36.920 --> 00:07:42.560 just think of some cheesy paars hanging off those branches with these furry men picking 109 00:07:42.560 --> 00:07:45.600 them off to eat them. So remember furry men eating cheesy paars. You 110 00:07:45.639 --> 00:07:48.360 can just think of these men with like big beards and they're eating these pears 111 00:07:48.600 --> 00:07:54.199 with just like nacho cheese. Dripping off of them. That's your clinical manifestations, 112 00:07:54.199 --> 00:07:56.199 and then I'll help you remember how it's going to present. Next, 113 00:07:56.279 --> 00:07:59.600 let's talk about physical exam. So physical exam is going to be different for 114 00:07:59.600 --> 00:08:03.600 each paine depending on the location and the size of the lesions. And some 115 00:08:03.680 --> 00:08:07.879 women may actually have a completely normal physical exam, which in no way rules 116 00:08:07.879 --> 00:08:11.079 out the disease. But if a patient does have positive physical exam findings, 117 00:08:11.279 --> 00:08:15.720 what should you be looking for? So that's going to be focal tenderness on 118 00:08:15.839 --> 00:08:20.199 vaginal exam, nodules in the posterior formix at nexticle masses at nexticle mass if 119 00:08:20.240 --> 00:08:24.040 you're not familiar with the term, just means a mass of the ovary, 120 00:08:24.079 --> 00:08:28.959 fillopian tube or the surrounding area, immobility, fixed or lateral placement of the 121 00:08:28.000 --> 00:08:33.559 cervix or uterus. Sometimes may also hear of the uterus being retroverted as well. 122 00:08:33.080 --> 00:08:35.360 So these are just some general things to be aware of. But again 123 00:08:35.600 --> 00:08:39.080 this isn't the highest yealed thing to know because many women may have a completely 124 00:08:39.120 --> 00:08:43.360 normal physical exam. All right, let's talk about diagnosis next. Now, 125 00:08:43.399 --> 00:08:48.200 the only way to definitively diagnose endometriosis is with a surgical biapsy going in cutting 126 00:08:48.200 --> 00:08:52.960 out some tissue sending it off to the lab. This is obviously quite invasive, 127 00:08:52.039 --> 00:08:56.679 so the alternative to this is to make a clinical diagnosis, so a 128 00:08:56.720 --> 00:09:01.360 presumptive clinical diagnosis. It's based on symptom signs and imaging findings. So you 129 00:09:01.360 --> 00:09:05.039 have a patient who has the furry men eating cheesy paar symptoms, they may 130 00:09:05.080 --> 00:09:09.080 have some of the typical physical exam findings we went over. Ultrasound can also 131 00:09:09.120 --> 00:09:13.600 be utilized and it's typically the first line modality when imaging is indicated, and 132 00:09:13.639 --> 00:09:18.279 what it may show is something known as an endometrioma, and endometrioma is a 133 00:09:18.320 --> 00:09:24.679 cystic mass arising from ectopic endometriol tissue. Usually this is in the ovaries. 134 00:09:24.919 --> 00:09:28.519 You'll sometimes here being referred to as a chocolate cyst because it contains thick, 135 00:09:28.799 --> 00:09:33.360 brown tar like fluid or old blood, so chocolate in appearance. I suppose 136 00:09:33.600 --> 00:09:37.879 MRI is another imaging modality that may be utilized in some patients, although ultrasound 137 00:09:37.919 --> 00:09:43.720 is usually favored as it's cheaper, available at most facilities, and the sensitivity 138 00:09:43.720 --> 00:09:46.519 and specificity are similar between the two. So those are the components of a 139 00:09:46.559 --> 00:09:52.559 clinical diagnosis signs, symptoms, and imaging findings, and a clinical diagnosis would 140 00:09:52.559 --> 00:09:56.279 be appropriate for a patient with mild to moderate symptoms, a patient who you're 141 00:09:56.320 --> 00:10:00.720 going to treat with lower risk meds like nsets hormonal contraceptives. What I think 142 00:10:00.720 --> 00:10:03.559 you should remember for the exam is how to make your definitive diagnosis, because 143 00:10:03.759 --> 00:10:07.360 they love to ask on exam questions how are you going to make a definitive 144 00:10:07.399 --> 00:10:11.440 diagnosis for disease? And the way you do that is as we went over 145 00:10:11.480 --> 00:10:16.080 before, and that's with a laparoscopy and biopsy, which involves a small incision, 146 00:10:16.399 --> 00:10:20.440 throwing some cameras in the abdomen, finding a suspicious lesion, setting it 147 00:10:20.440 --> 00:10:24.399 off for biopsy, and confirming it was indeed an endometril gland or stroma occurring 148 00:10:24.440 --> 00:10:30.879 outside of the uterine cavity. Laparoscopy can serve as both a diagnostic and therapeutic 149 00:10:30.919 --> 00:10:33.200 tool, as when the lesions are visualized, they can also be removed, 150 00:10:33.440 --> 00:10:37.240 improving the pain for some women. So this is obviously much more invasive than 151 00:10:37.240 --> 00:10:41.960 a clinical diagnosis, and it's going to be reserved for patients with more severe 152 00:10:41.039 --> 00:10:45.399 pain, patients who aren't responding to some of those first line meds will go 153 00:10:45.440 --> 00:10:48.320 over shortly as well as some other indications. So again for diagnosis, you 154 00:10:48.399 --> 00:10:52.279 can make a clinical diagnosis based on signs, symptoms, and imaging findings. 155 00:10:52.399 --> 00:10:56.440 Remember ultrasound if you do need imaging. But if you want to make a 156 00:10:56.480 --> 00:11:01.120 definitive diagnosis, that's done surgically through laparoscopy. And let's talk about treatment next. 157 00:11:03.399 --> 00:11:07.480 So I wanted to quickly talk about today's sponsor, an amazing tool for 158 00:11:07.519 --> 00:11:11.360 PA students called true Learn. 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You can visit true learn dot com to sign up, or 165 00:11:35.320 --> 00:11:37.399 click the link in the show notes and make sure to use the code cram 166 00:11:37.480 --> 00:11:41.039 the pants when signing up to save off subscriptions of ninety days or more. 167 00:11:41.440 --> 00:11:48.679 Now back to the show. So a treatment of endometriosis related pain, we 168 00:11:48.720 --> 00:11:52.519 can manage this with medication or with surgery. Let's start with the meds. 169 00:11:52.759 --> 00:11:58.120 There's a few different classes and meds, hormonal contraceptives and says on rh analog 170 00:11:58.200 --> 00:12:03.799 stanazol. There really isn't any compelling data to suggest one class over another based 171 00:12:03.799 --> 00:12:09.240 on efficacy, as they all have been found to have relatively similar clinical efficacy 172 00:12:09.279 --> 00:12:13.440 for reduction of pain. So that being said, as efficacy is similar between 173 00:12:13.440 --> 00:12:16.080 the classes, your first line meds are going to be based more on cost, 174 00:12:16.159 --> 00:12:20.480 availability, side effect profile, etc. So in women with mild to 175 00:12:20.519 --> 00:12:26.559 moderate pain, your first line treatment is generally going to be your combined estrogen 176 00:12:26.639 --> 00:12:31.039 progestin contraceptives. These are going to be first line treatment for most women with 177 00:12:31.200 --> 00:12:35.960 endometriosis related pain. Continuous regiments are found to be more effective at reducing pain 178 00:12:35.000 --> 00:12:39.919 than cyclic regiments, so it's best to take this continuously, so no hormone 179 00:12:39.919 --> 00:12:43.120 free intervals during the month. So why do we start with this class if 180 00:12:43.159 --> 00:12:46.399 we don't have compelling data to suggest one class over another regarding efficacy. But 181 00:12:46.519 --> 00:12:50.080 like I just talked about briefly before, it's because compared to other classes of 182 00:12:50.120 --> 00:12:54.120 meds, contraceptives are cheap, they're pretty well tolerated, and they can be 183 00:12:54.200 --> 00:12:58.120 used long term, whereas most of the other classes will go over generally do 184 00:12:58.159 --> 00:13:03.679 not possess these careacteristics. So the combined contraceptives are thought to reduce pain and 185 00:13:03.720 --> 00:13:09.159 disease activity through suppression of ovariant function causing atrophy of endometrio tissue. And of 186 00:13:09.200 --> 00:13:11.840 all of the treatments I'm going to go over for endometriosis, if you're going 187 00:13:11.879 --> 00:13:15.399 to remember just one, this would be the one I would say to focus 188 00:13:15.440 --> 00:13:18.679 on your birth control, your contraceptives, and if a woman is unable to 189 00:13:18.720 --> 00:13:24.360 take combined contraceptives, progestin only therapy is an alternative next end sets, So 190 00:13:24.519 --> 00:13:28.480 n sets are technically still suggested as one of the first line treatment options for 191 00:13:28.600 --> 00:13:31.960 endometriosis related pain. This is from the a COG guidelines and up to date, 192 00:13:33.559 --> 00:13:35.360 and for some of the same reasons we use contraceptives. They're low cost, 193 00:13:35.440 --> 00:13:39.600 readily available, so these will often be used in combination with contraceptives. 194 00:13:39.879 --> 00:13:43.519 But the thing you need to keep in mind is there's not any high quality 195 00:13:43.600 --> 00:13:48.200 data to support their use. We know they work well for other forms of 196 00:13:48.200 --> 00:13:52.320 pelvic pain. They're effective for primary dysmentary but the data just is really lacking 197 00:13:52.360 --> 00:13:56.320 to prove their efficacy in endometriosis, but we still use them because of their 198 00:13:56.360 --> 00:14:00.639 low cost, etc. Okay, next, let's talk about gener EH analogs. 199 00:14:00.679 --> 00:14:05.440 This there's another important treatment options, your GnRH analogs, so your gonadotropin 200 00:14:05.519 --> 00:14:13.480 releasing hormone analogs GENERH analogs include your GnRH agonists like laproulide or your GnRH antagonists 201 00:14:13.519 --> 00:14:18.759 like elagolis. These meds downregulate the pituitary ovarian axis, decreasing estrogen, which 202 00:14:18.799 --> 00:14:24.679 ultimately induces amenorrhea and endometrio atrophy, leading to improvement in pain. Now, 203 00:14:24.679 --> 00:14:28.000 they're usually not first line, and it's not due to lack of efficacy, 204 00:14:28.159 --> 00:14:31.720 but more due to the fact that there's more side effects and limitations on long 205 00:14:31.799 --> 00:14:35.919 term use. They can cause hypoestrogenic side effects like decreased libido, mood swings, 206 00:14:35.960 --> 00:14:39.960 headaches, decreased bone density. So reduce these side effects, there's something 207 00:14:41.039 --> 00:14:45.320 called add back therapy. This is where you add back hormones, usually progestin, 208 00:14:45.679 --> 00:14:48.440 and this improves some of the hypoestrogenic side effects. So again this class 209 00:14:48.480 --> 00:14:52.600 is no less effective than our contraceptives, but due to more side effects as 210 00:14:52.639 --> 00:14:56.720 well as limitation with how long these meds can safely be used for six to 211 00:14:56.720 --> 00:15:01.039 twelve months. Generally, they're usually second line meds and more reserved for patients 212 00:15:01.039 --> 00:15:05.200 with severe symptoms or patients refractory to your first line agents. Next, we 213 00:15:05.240 --> 00:15:09.639 have danozol. It's an androgenic drug that works really well. The problem is 214 00:15:09.679 --> 00:15:13.440 the side effect profile of danazol is not so good acne edema, weight gain, 215 00:15:13.519 --> 00:15:18.000 hersaitism, voice deepening, milegas, so it's often not used due to 216 00:15:18.039 --> 00:15:20.759 this. So those are the main meds to remember. Obviously, remember your 217 00:15:20.759 --> 00:15:24.320 contraceptives, that's the big one, and said's GnRH analogues and then danozol. 218 00:15:24.919 --> 00:15:28.399 Those are the ones that I would focus on again really focusing in on your 219 00:15:28.399 --> 00:15:33.679 contraceptives. Let's talk about surgery next. So surgery is obviously more invasive, 220 00:15:33.799 --> 00:15:37.159 more expensive, can be associated with complications, so surgery is usually going to 221 00:15:37.200 --> 00:15:43.120 be reserved for patients who have tried and failed medications, patients with contraindications to 222 00:15:43.159 --> 00:15:46.879 meds, patients with obstructions of the urinary or GI tract, and there's two 223 00:15:46.919 --> 00:15:52.639 main options for surgery. You have your conservative approach and then your more definitive 224 00:15:52.799 --> 00:15:56.879 invasive approach, which is with a hysterectomy. Let's start with a conservative approach 225 00:15:56.960 --> 00:16:00.519 first, and that's with a laparoscopic excision and or ablation. Now, this 226 00:16:00.559 --> 00:16:07.039 is usually first line surgical option because this procedure preserves fertility and hormone production. 227 00:16:07.279 --> 00:16:10.720 It's less invasive than a hysterectomy, so this is usually where you'll start with 228 00:16:10.759 --> 00:16:15.240 your surgical options. So the same laparoscopy we discussed before being used as a 229 00:16:15.279 --> 00:16:18.759 diagnostic tool to make a definitive diagnosis. Well, as I talked about before, 230 00:16:18.759 --> 00:16:22.120 it can be therapeutic when they go in and they're obtaining tissue for biopsy. 231 00:16:22.240 --> 00:16:26.240 They can also remove the suspicious lesions to improve the patient's symptoms. The 232 00:16:26.240 --> 00:16:30.879 problem is, while there is typically significant pain relief after the procedure, pain 233 00:16:30.919 --> 00:16:34.240 recurrence is fairly common. So in women with debilitating symptoms, who have no 234 00:16:34.399 --> 00:16:40.720 plans for future childbearing, and who have failed both medical therapy and conservative surgical 235 00:16:40.759 --> 00:16:45.759 therapy, these women would be candidates for a hysterectomy with or without upherrectomy. 236 00:16:45.039 --> 00:16:48.919 This is obviously last line treatment as it's more invasive and obviously due to the 237 00:16:48.919 --> 00:16:52.679 loss of fertility with this type of surgery, but it can be a definitive 238 00:16:52.679 --> 00:16:57.159 option for some patients. So just a quick bit of info on the with 239 00:16:57.360 --> 00:17:00.399 or without upherrectomy part. If you're doing to hys direct me anyways, you're 240 00:17:00.399 --> 00:17:04.240 removing the uterus, why not just remove the ovaries in all women, which 241 00:17:04.240 --> 00:17:08.920 would likely increase the efficacy of the surgery. While in premenopausal women, once 242 00:17:08.960 --> 00:17:14.839 you remove the ovaries, menopause begins, so you induce premature menopause, meaning 243 00:17:14.880 --> 00:17:18.279 all of the symptoms and risks associated with menopause begin. So if this was 244 00:17:18.319 --> 00:17:22.440 an older woman that's close to menopause anyways, hys directed me with upherrectomy may 245 00:17:22.440 --> 00:17:27.559 be appropriate. Or if a woman has extensive disease involving the ovaries, whufherrectomy 246 00:17:27.640 --> 00:17:30.920 also would be appropriate, but this is obviously going to be a case by 247 00:17:30.920 --> 00:17:36.119 case basis depending on the patient involved. So that's endometriosis. There's a lot 248 00:17:36.160 --> 00:17:38.519 to know. Let's do a thirty second recap of the highlights. Then let's 249 00:17:38.519 --> 00:17:42.480 talk about a mnemonic to help you remember the highest yield points. So endometriosis 250 00:17:42.519 --> 00:17:48.119 what is it endometrio tissue occurring outside of the uterus? Where is it most 251 00:17:48.200 --> 00:17:52.440 commonly found the ovaries? How is your patient going to present furree men eating 252 00:17:52.519 --> 00:17:56.000 cheesy pears? How do you definitively diagnose cut it out in biopsy? What's 253 00:17:56.039 --> 00:18:00.319 your first line? MAD usually going to be contraceptives can often be combined with 254 00:18:00.440 --> 00:18:04.400 en seids. Surgery is going to be reserved for severe or refractory cases. 255 00:18:04.480 --> 00:18:07.759 Now, what about the mnemonic? Well, back to the meat tree we 256 00:18:07.799 --> 00:18:12.279 talked about before endometriosis. So most of the HyG old points about endometriosis are 257 00:18:12.319 --> 00:18:17.480 in and around that meat tree. So every time you hear endo meat triosis, 258 00:18:17.519 --> 00:18:19.240 I want you to think of that meat tree we talked about before, 259 00:18:19.559 --> 00:18:23.400 a tree with meat hanging from its branches. As remember that's not where meat 260 00:18:23.480 --> 00:18:27.400 is supposed to be found, which will help you remember what endometriosis is meat 261 00:18:27.480 --> 00:18:33.119 or tissue, endometro tissue specifically where it's not supposed to be found. Now, 262 00:18:33.160 --> 00:18:34.880 next to that met tree, there's some furry men hanging out and they're 263 00:18:34.920 --> 00:18:38.599 snacking on some cheesy pears they pulled off the tree. That helps remember the 264 00:18:38.640 --> 00:18:44.839 common clinical manifestations you'll likely find in the vignette, which is infertility, furry 265 00:18:45.119 --> 00:18:51.319 dys men area, men, dyskesia or dyschiesia, cheesy and dispair Unia pairs 266 00:18:51.720 --> 00:18:55.039 next on the trunk of the tree, like any cartoon tree you've ever seen 267 00:18:55.079 --> 00:18:57.799 before, there's always that little oval hole in the trunk with a bird or 268 00:18:57.880 --> 00:19:02.079 squirrel hanging out in it. So on our tree, on the trunk there's 269 00:19:02.119 --> 00:19:07.480 a small oval opening and oval helps you remember ovaries are the most common area 270 00:19:07.519 --> 00:19:10.480 to be affected. And then there's a bird hanging out in that hole to 271 00:19:10.480 --> 00:19:15.680 help you remember birth control bird aka contraceptives, which is the first line meds 272 00:19:15.759 --> 00:19:19.599 bird birth control. So endometriosis meet hanging from a tree, bunch of furry 273 00:19:19.599 --> 00:19:23.279 men around the tree eating cheesy pears, oval hole at the trunk of the 274 00:19:23.319 --> 00:19:26.720 tree with a bird hanging out in it, and that's endometriosis. Let's do 275 00:19:26.759 --> 00:19:30.160 a few quick questions to test your knowledge. Question one, a thirty two 276 00:19:30.240 --> 00:19:36.279 year old Nola, Paris woman complains of dysmenorrhea that has become progressively worse over 277 00:19:36.319 --> 00:19:41.599 the past few years. She also reports experiencing difficult, painful defecation, diskesia 278 00:19:41.839 --> 00:19:47.279 and painful sexual intercourse dysperonia. The patient and her partner have been trying unsuccessfully 279 00:19:47.319 --> 00:19:49.759 to conceive for the last year. She has tried over the counter end sets 280 00:19:49.759 --> 00:19:53.000 for pain relief, but does not find them to be very effective. Upon 281 00:19:53.039 --> 00:19:59.279 pelvic examination, focal tenderness and immobility of the uterus is noted. A presumptive 282 00:19:59.279 --> 00:20:03.200 clinical diagnose of endometriosis is made. Her primary goal is pain management, as 283 00:20:03.200 --> 00:20:07.839 she is not planning to conceive at this time. In the absence of contraindications, 284 00:20:07.039 --> 00:20:11.039 which of the following medications would be the most appropriate option to try next? 285 00:20:11.559 --> 00:20:18.640 A combined contraceptive b g nrh agonist, C danizol or d g nrh 286 00:20:18.799 --> 00:20:25.319 antagonist. So again, which of the following medications would be most appropriate to 287 00:20:25.319 --> 00:20:29.839 try next? And that is going to be a combined contraceptive. So we 288 00:20:29.880 --> 00:20:33.960 have a classic presentation for endometriosis. We have a patient with dysmenorrhea and fertility 289 00:20:34.039 --> 00:20:38.359 dyskesia and dysperunia. So the furry men eating cheesy pair symptoms we went over 290 00:20:38.400 --> 00:20:42.119 earlier. On physical exam, you have focal tenderness, a fixed uterus. 291 00:20:42.279 --> 00:20:47.279 We see she's tried N sets with minimal pain relief, so which medication class 292 00:20:47.279 --> 00:20:49.160 would be most appropriate to try next? Well, right off the bat, 293 00:20:49.160 --> 00:20:52.480 we can eliminate danozol as we discussed before, it has a lot of side 294 00:20:52.480 --> 00:20:56.359 effects and will not be a first line men so we're left with contraceptives and 295 00:20:56.440 --> 00:21:00.519 a GnRH analog. While they both have similar efficacy, we know we usually 296 00:21:00.559 --> 00:21:06.039 start with contraceptives due to the more favorable side effect profile and the ability to 297 00:21:06.119 --> 00:21:10.440 use these medications long term compared to GENERH analogs, which are generally limited to 298 00:21:10.480 --> 00:21:15.519 six to twelve months and also require adback therapy to combat the hypoestrogenic side effects. 299 00:21:15.599 --> 00:21:18.400 So again, that is going to be a combined contraceptives. Question two, 300 00:21:18.720 --> 00:21:23.240 in order to establish a definitive diagnosis for the patient described above, which 301 00:21:23.240 --> 00:21:29.519 of the following diagnostic procedures would be the most appropriate choice? A laparoscopy with 302 00:21:29.559 --> 00:21:37.599 biopsy, b ultrasound, cMRI, or DCT computed tomography. So that is 303 00:21:37.640 --> 00:21:41.680 going to be a laparoscopy with biopsy. So remember, the only way to 304 00:21:41.720 --> 00:21:48.839 definitively diagnose endometriosis is with tissue biopsy, which is typically obtained during laparoscopic surgery. 305 00:21:48.200 --> 00:21:52.279 So locating and cutting out tissue and sending it off to the lab. 306 00:21:52.599 --> 00:21:56.599 MRI and ultrasound can be used in the initial workup, but will not provide 307 00:21:56.640 --> 00:22:00.799 a definitive diagnosis, and CT is generally not util in the diagnostic workup due 308 00:22:00.799 --> 00:22:06.279 to exposure of ionizing radiation to the patient as well as low test sensitivity. 309 00:22:06.440 --> 00:22:10.640 Question three, A laparoscopy with biopsy is performed on the patient described above, 310 00:22:10.880 --> 00:22:15.359 confirming the diagnosis of endometriosis. The provider informs the patient that the endometrio lesians 311 00:22:15.400 --> 00:22:21.279 found were located in the most common site for endometriosis. What area of the 312 00:22:21.319 --> 00:22:26.799 body would the provider likely be referring to, So that is going to be 313 00:22:26.880 --> 00:22:30.599 the ovaries. So the ovaries are the most common sight for endometriosis, seen 314 00:22:30.640 --> 00:22:33.759 in up to sixty seven percent of women with this condition. Okay, so 315 00:22:33.839 --> 00:22:36.759 that was endometriosis. I hope that was helpful. Thank you so much for 316 00:22:36.799 --> 00:22:40.519 listening, and if you're enjoying the podcast, a five star review really helps 317 00:22:40.519 --> 00:22:42.200 get the word out about the podcast. Thank you again for listening, and 318 00:22:42.279 --> 00:22:44.359 best of luck in school.