Cram The Pance - S1E53 Endometriosis

Episode Date: May 5, 2024

High Yield Endometriosis ReviewReview for your PANCE, PANRE, Eor's and other Physician Assistant exams.TrueLearn PANCE/PANRE SmartBank:https://truelearn.referralrock.com/l/CRAMTHEPANCE/Discount code for 15% off: CRAMTHEPANCE Merchandise Link: https://cram-the-pance.creator-spring.com/►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)Included in review: Endometrioma, Contraceptives, GNRH Analogues, GNRH agonist, GNRH antagonist, Danazol, Chocolate cyst, Dysmenorrhea, Dyspareunia, Dyschezia, Infertility.Become a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so today we're going to be talking about endometriosis. A big thank you to everybody who's left a nice comment, everybody who's shared the podcast or YouTube channel with a friend or a classmate. I really appreciate it. So thank you so much. Let's go ahead and get started with endometriosis. So endometriosis, it's a pretty high-yield topic. There's a decent amount to know.

I do have a mnemonic that's going to kind of help you remember most of the high-yield points that you need to know. So let's go ahead and get started. Endometriosis. What is endometriosis? Well, endometriosis is a condition where endometrial 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. It has a number of functions

related to reproduction, mencies, implantation, gestation, labor and delivery, etc. We have the wall of the uterus, which has three layers. We have the parametrium or serosa, 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 endometrial 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 ones inside of the uterus, they undergo the same cyclic changes each month, which causes inflammation, scarring, adhesions, bleeding, and a number of other problems we'll go over shortly. So again, endometriosis, it's endometrial tissue occurring outside of the uterine 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 endometriosis. Endometriosis, meat as in steak and tree like a tree with branches and leaves. So when you see the word endometriosis, think endometriosis. 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, endometriosis, 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 uterine cavity. So where can we find these adventurous ectopic endometrial cells? Well, all over the body, really, the bowel, the bladder, posterior broad ligaments, even the diaphragm and pleural cavity up in the lungs. The lesions typically, though, will be found within the pelvis and the most common sight specifically of endometriosis and the one you need to know for the exam, that's the ovaries.

Overs are the most common site 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 100% 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, imbalanced 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 Dr. Samson. 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 mencies, which can result in endometrial cells implanting themselves in different areas, where they ain't supposed to be. Sounds really simple, but the problem of this theory is is that we've come to realize that retrograde menstruation, it's actually really common. Around 90% of women have retrograde menstruation, but only around 10% 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 100% 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, nulliparity, so women having no previous births, early men are key, 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 endometrial cells have the same estrogen receptors as endometrial 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 bad. pain. Abdominal, pelvic, pain is quite common. This can be described as dull, throbbing, sharp, or burning. Dismanorrhea or painful menstruation. This can be very severe in some women. Disparonia, which is pain with sexual intercourse. This is more suggestive of peritoneal lesions or deep endometriosis lesions. Dischasea, 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 this 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 macduration. Some patients may have chest pain, hemoptosis. 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 dysmenorrhea, dysperonia, dyskessia, and infertility. They will almost certainly give you a patient in their reproductive years, having trouble getting pregnant, complaining of severe pain with mencies, 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 pairs. It's a very weird picture to paint in your head. That's why you'll remember it. Furry is going to help you remember infertility. Men helps you remember dysmenorrhea. Cheesy helps you remember dyschesia, or dischisia, as I used to pronounce it. And pear helps you remember dysperunia. Think back to your meat tree.

Now just think of some cheesy pears hanging off those branches with these furry men picking them off to eat them. So remember furry men eating cheesy pears. You can just think of these men with like big beards. And they're eating these. pairs with just like nacho cheese dripping off of them. That's your clinical manifestations and 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 patient 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 fornics. Adnexyl masses. Adnexel mass, if you're not familiar with the term, just means a mass of the ovary, fallopian tube, or the surrounding area. Immobility, fixed, or lateral placement of the cervix or uterus. Sometimes you 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 yield 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 biopsy. 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 symptoms, signs, and imaging findings.

So you have a patient who has the furry men eating cheesy pear 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. An endometrioma is a cystic mass arising from ectopic endometrial 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 insets, 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, sending it off for biopsy, and confirming it was indeed an endometrial gland or stroma occurring outside of the uterine cavity. Laperoscopy 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 biopsy. Let's talk about treatment next. So I wanted to quickly talk about today's sponsor, an amazing tool for PA students called True Learn. True Learn is a game-changing solution for students preparing for the pants exam or just for some extra help during didactic year true learn's test bank offers over 900 test items specifically designed for the pants and 1100 items for the pan re the questions are created by board certified physician assistants who understand the exam's nuances and you can conveniently access true learns content through their website or their user-friendly mobile app perfect for studying on the go you can visit truleon.com to sign up or click

the link in the show notes and make sure to use the code cram the pants when signing up to save an off subscriptions of 90 days or more. Now, back to the show. So 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, nseds, CNRH analog, stanzol.

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 with 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 regimens are found to be

more effective at reducing pain than cyclic regimens. 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 you're we don't have compelling data to suggest one class over another regarding efficacy. Well, 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 characteristics. So the combined contraceptives are thought to reduce pain and disease activity through suppression of ovarian function, causing atrophy of endometrial tissue.

And of all of the treatments, I'm going to go over for endometriosis, if you're gonna 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, inseds. So, inseds are technically still suggested

as one of the first line treatment options for endometriosis related pain. This is from the ACOG 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 dysmenorrhea, but the data just is really lacking to prove their efficacy in endometriosis, but we still use them because of their low cost, et cetera. Okay, next let's talk about GNRH analogs. This is another important treatment options, your GNRH analogs, so your gonadotropin releasing hormone analogs. GNRH analogs include your GNRH agonis like lapulide or your GNRH.

N-R-H antagonists like alygolix. These meds downregulate the pituitary ovarian access, decreasing estrogen, which ultimately induces ameneria and endometrial 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 12 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 danazole. 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, hercetism, voice deepening myelgias. So it's often not used due to this. So those are the main meds remember. Obviously remember your contraceptives. That's the big one. Nseds, GNRH analogs. And then Danazol. 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. It 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. 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, while as I talked about before, it can be therapeutic. When they go in, they're obtaining tissue for biopsy. They can also remove the suspicious lesions to improve the patient's symptoms. 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 ophorectomy. 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 ophorectomy part. If you're doing the hysterectomy anyways, you're removing the uterus. Why not just remove the ovaries in all women which would likely increase the efficacy of the surgery. Well, 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, hysterectomy with ophorectomy may be appropriate. Or if a woman has extensive disease involving the ovaries, uferectomy also would be appropriate. But this is obviously going to be a case-by-case basis depending on the patient involved. So that's That's endometriosis. There's a lot to know. Let's do a 30 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? Endometrial tissue occurring outside of the uterus. Where is it most commonly found? The ovaries. How is your patient going to resent? How is your definitively diagnose? Cut it out in biopsy. What's your first line med usually going to be? Controceptives. This can often be combined with enseds. 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 high yield points about endometriosis are in and around that meat tree. So every time you hear endometriosis, I want you to think of that meat tree we talked about before, a tree with

meat hanging from its branches. As you remember, that's not where meat is supposed to be found, which will help you remember what endometriosis is, meat or tissue, endometriot tissue specifically where it's not supposed to be found. Now, next to that meat tree, there's some furrying men hanging out and they're snacking on some cheesy pairs they pulled off the tree. That helps remember the common clinical manifestations you'll likely find in the vignette, which is infertility, furry dismenorrhea, men, dischesia, cheesy, and disperunia 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, meat hanging from a tree, a 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 32-year-old Nola Paris woman complains of disminor.

that has become progressively worse over the past few years. She also reports experiencing difficult, painful defecation, dyskhesia, 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 endseds 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 diagnosis of endometriosis is made. Her primary goal is pain-manage, 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, GnRH agonist, C, danazol, or D, GnRH 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 dysmerexia. We have a patient with dysmenorrhea, infertility, dyskezia, and dysperunia. So the furry men eating cheesy pear symptoms we went over earlier. On physical exam, you have focal tenderness, a fixed uterus. We see she's tried enseds with minimal pain relief.

So which medication class would be most appropriate to try next? Well, right off the bat, we can eliminate Danazol, as we discussed before, it has a lot of side effects and will not be a first-line med. 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 GNRH analogs which are generally limited to 6 to 12 months and also require ad back 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, C, MRI, or D, C, T, computer 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 utilize 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 endometrial lesions 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 67% of women with this condition. Okay, so that was endometriosis. I hope that was helpful. Thank you so much for listening.

And if you're enjoying the podcast, a five-star review really helps get the word out about the podcast. Thank you again for listening. And best of luck in school.