Patient Scenarios: Endometriosis

The scenarios are fictitious, but are similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers, but some pitfalls to avoid.

The following case studies, written by Dr Anne Connolly, relate to her article Top tips: suspecting and managing endometriosis and NG73, Endometriosis: diagnosis and management.

Case 1: Amy

Context

Amy is a 17-year-old student at the local college. She attends the clinic with her mother, who is concerned about how often Amy is absent from college because of her period problems. They are both worried that Amy will not be able to sit all her approaching exams, and—if she does manage to attend—whether she will be able to concentrate.

Amy’s periods are very painful, and have been since they started 5 years ago. The problem is becoming worse, and is now interfering with her education and social life. Her periods last for 4–5 days every month. She starts getting lower abdominal pain for 1–2 days before menstruating, which becomes worse for a few days, then stops when the bleeding finishes.

Amy does not have any urinary symptoms, but experiences diarrhoea when she is menstruating. She takes paracetamol and ibuprofen without much benefit. She does not take any other medication or have any other health concerns, but is feeling anxious and stressed about her period problems and the impact they are having on her life.

Questions for Reflection

1. What are the differential diagnoses?
2. What challenges may arise when obtaining a history from this patient? 
3. What examinations and investigations could be considered?
4. Should any scans be performed?
5. How should this patient be managed?
6. What advice would be helpful for this patient?
7. When should this patient be reviewed, and should she be referred to secondary care?

How to Manage This Patient

1. The main differential diagnoses are endometriosis, PID, and IBS. Dysfunctional uterine bleeding may also cause dysmenorrhoea, but usually becomes less problematic 2–3 years post-menarche 
2. One challenge in the consultation is obtaining a sexual history from Amy when her mother is present. It may be straightforward to obtain, but options include asking her mother to leave the room or creating an opportunity for discussion by taking Amy to the toilet for a urine sample
3. Abdominal examination should be performed and may reveal tenderness, but other findings are likely to be absent in younger women with endometriosis. If there is any risk of pelvic infection, a vaginal examination to assess for cervical excitation and/or adnexal tenderness is required at the first visit. Speculum examination is recommended by NICE, but is usually not required, as clinical findings are likely to be absent and are unlikely to change management. A vulvovaginal swab should be performed in those with any sexual risk, to exclude chlamydia and/or gonorrhoea infection 
4. NICE recommends that an ultrasound scan should be requested, as it can be used to support the diagnosis of endometriosis as well as to exclude endometriomas or alternative pathologies. A transvaginal scan is preferable (if acceptable), and a clear indication on the form that endometriosis is the likely diagnosis should be made, as the findings are likely to be minimal and will require careful assessment by the sonographer
5. The management of endometriosis can consist of hormonal treatments, nonhormonal analgesia, or surgery. Treatment should be commenced as soon as possible to reduce the potential longer-term complications of the disease, including subfertility, ectopic pregnancy, and chronic pelvic pain
   • hormonal intervention is preferable initially, with the ambition to prevent menstruation. Any hormonal contraceptive will give benefit, and a discussion about each is advised. Before using any CHC, a risk assessment is required; continuous use should be recommended to prevent any bleeding. Progestogen-only contraceptives are an alternative where appropriate or chosen
   • analgesia may also be used, alone or in addition to hormones. Analgesics may reduce pain symptoms, but do not change the progressive complications caused by the recurrent bleeding of endometriotic deposits. Starting analgesia when any symptoms arise will optimise its benefits
   • laparoscopic surgery is the ‘gold-standard’ treatment, but is generally not chosen or needed by many women with endometriosis initially. When performed, surgery should be undertaken by endometriosis experts, and includes diathermy or excision of endometriotic lesions
6. Advice given to Amy should include information about the condition, including the short- and long-term complications of untreated disease. The charity Endometriosis UK has many useful resources for clinicians and sufferers to help them understand the condition and the treatment options available to them
7. A review appointment after 3 months, or earlier if required, should be arranged to assess treatment outcomes and to offer further support. Referral to gynaecology services should be made if chosen by the patient, or if initial treatments do not provide sufficient benefit.

Case 2: Farah

Context

Farah is a 39-year-old teacher who is currently off work following her hysterectomy and BSO for the treatment of endometriosis, which were performed 3 weeks ago.

Farah has always had painful periods, but did not realise it was not ‘normal’ until after she married aged 28 years and dyspareunia became a problem for her. She has suffered with infertility, and after several attempts has given birth to one child after successful assisted conception.

Farah has had three laparoscopies to treat her endometriosis with minimal improvement, and finally underwent hysterectomy and BSO as she was unable to continue her work as a primary school teacher with the chronic pain she was suffering.

Farah attends surgery in tears. She is relieved that the surgery has gone well but she aches, is unable to sleep because of night sweats, and has experienced recurrent episodes of palpitations.

Examination

Farah’s surgical wound is healing well. Other clinical findings include:

• a temperature of 36.8°C
• a regular pulse of 68 BPM
• a BP of 115/78 mm Hg
• a BMI of 28 mg/kg².

Questions for Reflection

1. What are the differential diagnoses?
2. What investigations could be considered?
3. How should this patient be managed?
4. What advice and information would be helpful for this patient?

How to Manage This Patient

1. In this case, a differential diagnosis needs to include infection, stress, thyroid disease, and anaemia, in addition to the perimenopause symptoms she will be experiencing following her recent surgery
2. Examination of the wound appears normal, so no microbiological investigations are required. Hormone assays, including tests for FSH or oestradiol levels, are not necessary as they will likely confirm the largely inevitable diagnosis of perimenopause that occurs after BSO. Other tests should be considered to exclude coexisting problems, including an FBC, TFTs, and an ECG
3. The hypo-oestrogenism resulting from BSO causes severe acute perimenopausal symptoms and requires management with HRT where possible. For most women post-hysterectomy, an oestrogen-only HRT is the treatment of choice; however, following surgery for endometriosis, a continuous combined preparation is recommended to prevent hyperplastic change in any residual endometrium. As Farah has no other risk factors for use of HRT, she can choose an oral or a transdermal preparation
4. Farah may experience side effects from the combined HRT in the first few months, such as nausea, breast tenderness, or irritability. The majority of these symptoms will settle before review at 3 months; however, if any are concerning, she should be advised to contact the clinic for a discussion. If the side effects are significant or persistent, changing the HRT preparation to an alternative combination is recommended. If she experiences persistent vasomotor symptoms, she may require an increased oestrogen dose. At review, a discussion about vaginal dryness or discomfort should also be made, as additional topical vaginal oestrogen may be required.

NG=NICE Guideline; PID=pelvic inflammatory disease; IBS=irritable bowel syndrome; CHC=combined hormonal contraceptive; BSO=bilateral salpingo-oophorectomy; BPM=beats per minute; BP=blood pressure; BMI=body mass index; FSH=follicle-stimulating hormone; FBC=full blood count; TFT=thyroid function test; ECG=electrocardiogram; HRT=hormone-replacement therapy