04.03 Endometriosis

Hey guys, today’s lesson is on endometriosis. By the end of today’s lesson you’ll have a better understanding of what endometriosis is, symptoms of the disease, treatment options, as well as important patient education topics related to this disease process.

Hey guys so I want to do just a quick overview of what endometriosis is before digging in deeper. So endometriosis is an inflammatory condition that occurs when there is abnormal tissue growth outside the uterus that causes pain. So this abnormal tissue growth is when endometrial tissue that should be inside the uterus grows on the outside of the uterus. So since this tissue growing in spots that it shouldn’t be, this can cause pain and infertility. This picture shows endometriosis and shows the endometrial tissue growing on other structures that is not supposed to be there vs inside the uterus where the normal growth and shedding of the endometrial tissue occurs. Endometriosis is pretty common and is more prevalent in women ages 25-35. Having a mother with endometriosis is another risk factor with the disease because there is a strong hereditary component. Another risk factor for developing endometriosis is if a woman waits until later in life before becoming pregnant, because it exposes the woman to an increased number of menstrual cycles and also increases the number of episodes of retrograde menstruation which is basically when the menstrual blood backflows in the body. So the menstrual blood normally carries sloughed endometrial cells from the uterus which is fine if there is normal menstrual flow out of the body. But in instances where there is backflow, the blood and endometrial cells can travel upward through the fallopian tubes, to the ovaries, and pelvic cavity, allowing the opportunity for the tissue to implant and cause the development of endometriosis.

Okay guys so let’s go over the pathophysiology behind endometriosis. So the ectopic tissue, or the tissue that is growing abnormally, outside the uterus responds to hormone stimulation of estrogen and progesterone just as if it were in the uterus. This causes bleeding at the site of the abnormal tissue growth. Since it is cyclical, this means that this is happening monthly, or when the woman is menstruating. So the ectopic tissue bleeds and irritates the surrounding tissues causing inflammation. This increased inflammation can lead to fibrosis which then leads to adhesions. The formation of adhesions then causes pain, because it is not a normally occurring structure, and can cause infertility if it blocks the natural flow of eggs from the ovary.

So with the patient’s symptoms they usually are worse during menstrual years and resolve after menopause because it is a cyclical pattern and responds to hormone stimulation during menstruation. So once the woman hits menopause and her menses stop, there is no more cyclical hormonal stimulation, which means that the abnormal, cyclical bleeding stops as well. So guys the classic symptom of endometriosis is dysmenorrhea, or menstrual cramping, because it’s basically the body menstruating, but since the tissue is abnormally growing, the body can’t get rid of the blood normally like when the woman menstruates. So endometriosis can be kind of thought of a menstrual period that is stuck inside the woman’s body. The pain can be constant vs intermittent cramping seen with typical menstruation. The dysmenorrhea usually starts 5-7 days before menses and lasts for 2-3 days. This picture shows possible locations of endometriosis. So depending on where the tissue growth is, that is typically where the patient will have pain and symptoms. So the patient can have lower abdominal pain, which is the most common, but they can also have vaginal pain and posterior pelvic pain. Other symptoms that patients can have includes painful intercourse, hematuria and dysuria, as well as infertility. As with the area of tissue growth directly relating to where the patient has pain, these other symptoms are the same and depend on the location of the abnormal tissue growth.

Alright guys so let’s move on to diagnostics for endometriosis. So a pelvic exam can be performed and would show pelvic tenderness and the provider could feel lumps in the vagina. The pelvic tenderness and lumps in the vagina are both due to the abnormal tissue growth of endometrial tissue outside the uterus. A transvaginal ultrasound can be done to make sure it is endometriosis vs pelvic masses that can be mistaken for the disease. A laparoscopy can also be performed to both confirm the diagnosis and determine the stage of the disease. So this is really helpful when we are thinking about treatment options for these patients because if the disease is still in beginning stages, conservative management may be sufficient and would probably be the first step of treatment. This picture shows a laparoscopic picture of endometrial lesions at the peritoneum of the pelvic wall - so this is what the surgeon would be looking for in a laparoscopic procedure.

So treatment generally depends on patient’s symptoms, how advanced the endometriosis is, and the patient’s desire to have children. Usually non-surgical management is used with women who still want to have children, so it is a more conservative approach. Birth control can be used to help relieve the patient’s symptoms as well as help regulate the patient’s menstrual cycle. Heat packs can be applied to the abdomen for a soothing effect and to provide temporary pain relief, like women do when they are normally menstruating. Relaxation techniques like yoga, massage, and biofeedback can also help can also help with pain relief. Laparoscopy is used for surgical management in patients who still want to be fertile, by removing adhesions which reduces pain and helps with fertility. In patients with extensive disease like with masses present and there if there is no desire to have children, then the masses need to be removed to make sure they are not cancerous. The treatment of choice in these cases is a total abdominal hysterectomy with bilateral salpingo-oophorectomy. So the uterus, cervix, as well as both fallopian tubes and ovaries are all removed with this procedure. Of course we will be monitoring post surgical patients like we would with any other surgery - so monitoring for infection, wound care, and pain control are all important nursing interventions.

One of our biggest patient education points is going to be teaching about one of the complications of endometriosis, which is infertility. It’s important for patients to know that if they want children, they should not wait to have them and that treatment is very important to prevent or postpone infertility. We also want to be teaching about methods for pain control - so medications, heat packs, and surgery if indicated. It’s important that the patient understands the importance of routine evaluation as well as annual pelvic exams and pap smears to evaluate the disease progression as well as evaluate if anything else is going on since their last visit.

One of the nursing concepts associated with endometriosis is alterations in reproduction because infertility is a complication of the disease. Another nursing concept is an alteration in comfort as pain is one of the main symptoms seen with this disease process.

Alright guys, so there’s a few key points I want you to take away from today’s lesson. One is the symptoms of endometriosis, which includes dysmenorrhea, pain in different locations, painful intercourse, and infertility. There’s a few different options for diagnosis, which include a pelvic exam, transvaginal ultrasound, and laparoscopy. These tests are used to confirm the diagnosis as well as determine the stage of the disease. Remember guys, treatment is going to depend on the patient’s symptoms, how advanced the disease is, and if the patient wants to have children or not. There are several non-surgical as well as surgical management options available. Finally, we want to teach our patients about complications including infertility and the importance of not waiting until later in life to become pregnant if the patient wants to have children. We also want to remind them about the importance of annual pelvic exams and pap smears to evaluate the disease’s progression.

Okay guys, that is all for our lesson on endometriosis. Make sure to check out the other resources attached to this lesson. Now go out there and be your best self today, and as always, Happy Nursing!