en dome trios is presentation (5)

8/8/2019 En Dome Trios Is Presentation (5)

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ENDOMETRIOSIS

Eileen Gillespie, BSN, RNSacred Heart University

NU 560February 23, 2010


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Case Study

Jan is a new patient who comes in to seeyou with c/o severe dysmenorrhea forwhich she was diagnosed asendometriosis.


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Definition

Endometriosis occurs when functioningendometrial tissue is implanted outside the

uterine cavity into pelvic structures or in rarecases, other body structures


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Overview

The endometrial implants respondto cyclic hormonal changes andover time this monthly bleedingand healing leads to scarring and

adhesions (Rymer, et al 2005)

Common Sites forImplantation

Ovaries Fallopian tubes Uterine ligaments Pelvic cul-de-sac Pelvic peritoneum

Definite cause is unknownTheories Include:

Implantation via retrograde menstruationinto other structures within the pelvis or

abdomen spread and implantation via vascular and

lymphatic vessels to ovaries and distant

sites Immune system weakness that allows

implantation Coelomic Metaplasia : undifferentiated

cells in the pelvis with the properstimulus, may grow and differentiate into

endometrial cells. (medscape 2009)


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A rriving at the DiagnosisHistory / Interview

Obtain a detailed history of symptoms and painObtain a detailed obstetric and menstrual historyInquire if the pain affect her relationships or activities of daily life?Inquire if the pain affect intimacy with her significant other?Discuss pain and symptom management choicesDiscuss her pregnancy plans if any

40 - 50 % of women with moderate to severe endometriosis have fertilityproblems (Leavitt 2010)

Discuss the possibility of corrective procedures / surgery Conservative ( fertility sparing)

Laser ablation or excision

Surgical excision Radical (not fertility sparing)

TAH / BSO


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Collected Information

Symptoms dysmenorrhea dyspareunia dyschezia

chronic pelvic pain infertility

Depend on the location of implants

Risk Factors Childbearing age Nonparous or delayed

childbirth Family hx Hx PID Hx of shortened cycle (


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Diagnostic TestsPelvic examTransvaginal UltrasoundLaparoscopy: Preferred approach

Can stage, biopsy, and correct simultaneously Staged according to extent and type of lesions

A dhesions between the left ovaryand pelvic wall.

A dvanced Endometriosis withdense adhesions


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A vailable MedicationsHormonal contraceptivesGonadotropin-releasing hormone (Gn-RH)agonists and antagonists.

DanazolMedroxyprogesteroneAromatase inhibitorsAnalgesicsNSAIDS


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Developing the Plan

W hat now?

Determine how she was diagnosed clinical suspicion? direct visualization?

Develop a treatment plan based on hersymptoms, stage, and future plans.


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Treatment PlanThe FNP should focus on reducing symptoms and improving qualityof life with a multi-disciplinary approachObtain a definitive diagnosis with laparoscopy if necessaryTreatment

Focused on patient s symptoms and desires. Pain managementCombination Oral Contraceptives: reduce estrogen / progesterone secretionleading to atrophy of implantsCox 2 Inhibitors: reduce chronic inflammation associated with endometriosis(preferred for once a day dosing)

Psychological counseling if depression is associated with symptoms Fertility counseling if the patient is planning on pregnancy

Consider surgical consult for conservative laparoscopic surgery or ablationto increase fertility

Involve family and friends to assist patient if necessary Recommend support groups


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Treatment PlanAdvanced disease, failed medical regimen, or desire forattempted pregnancy:

Referral to Specialists ( Surgeon, Infertility Specialists) Surgery

Conservative (to prepare for possible pregnancy or symptom relief)

Radical (fertility sparing not required) Pain management

Analgesics for post operative pain Hormone Replacement and / or return to preoperative treatment to

prevent recurrence if pregnancy not a goal Psychological counseling if depression continues or if TAH/BSO is

indicated or completed Fertility counseling if the patient is planning on pregnancy Risk counseling for possible adverse pregnancy outcomes


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RESOURCES

http://www.acog.org/publications/patienteducation/bp013.cfm

http://www.ehealthmd.com/library/endometriosis/ EM_whatis.htmlhttp://www.obgyn.net/


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Q UESTIONS?


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References

Bulun S E. Endometriosis. N Engl J Med . 2009;360:268-279.Katz VL, Lentz GM, Lobo RA, Gershenson DM.Compr ehensive Gynec o l ogy . 5th ed. Philadelphia, Pa:Mosby Elsevier; 2007:chap. 19.

Leavitt, K. End o-R es o lved. 2010 http://www.endo-resolved.com/index.html accessed February 18, 2010.McChance K, Huether S, Pathophysiology. 5 th ed.Philadelphia, Pa: Mosby Elsevier; 2006:chap.23.Mounsey AL. Diagnosis and management of endometriosis. A m Fam Physician . 2006;74(4):594-600.O Reilly B, Bottomley C, Rymer, J. Obstetrics andGynaecology. Elsevier Saunders 2005: chapter 6. pp 77-84

en dome trios is presentation (5)

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