endometriosis/fibroids/abortion

What is the pathophysiology of endometriosis?

Growth of endometrial-like tissue outside the uterus causing chronic, estrogen-dependent inflammation. Common sites: fallopian tubes, ovaries.

What is retrograde menses?

Endometrial tissue flows backward through the fallopian tubes into the abdominal cavity; ~90% of women experience it but only ~10% have symptoms.

Major complications of endometriosis?

Infertility (30–50%), higher risk of preterm birth, miscarriage, small-for-gestational-age infants, and cesarean delivery

Risk factors for endometriosis?

Early menarche (<11), short cycles (<27 days), heavy/prolonged menses, family history (7–10× risk). Protective: multiple births, regular exercise

Most common symptom of endometriosis?

Pelvic pain at the start of menses

: Other symptoms of endometriosis?

Dyspareunia, dysmenorrhea, back pain, dysuria, heavy bleeding, fatigue, N/V.

First-line pharmacologic treatments for endometriosis?

NSAIDs, combined oral contraceptives, progestins (e.g., norethindrone acetate 5 mg

MOA of GnRH agonists in endometriosis?

They overstimulate GnRH receptors → temporary estrogen flare → receptor desensitization → suppression of estrogen

MOA of GnRH antagonists?

Block GnRH receptors immediately → ↓ FSH/LH → rapid estrogen suppression without flare.

Examples of GnRH antagonists?

Elagolix, Relugolix/estradiol/norethindrone

Last-line drug class for endometriosis?

Aromatase inhibitors (e.g., letrozole)

When should symptom improvement occur after starting therapy?

Within ~2 months.

What tool can measure subjective improvement?

SF-36 questionnaire

What are uterine fibroids?

Noncancerous growths made of smooth muscle and fibroblasts in/around the uterus.

Prevalence of fibroids by age 50?

70–80%. Shrink after menopause

Most common indication for hysterectomy?

Uterine fibroids.

Risk factors for fibroids?

Early menarche (<10), age 30–40, Black race, genetics, obesity. Protective: parity ≥1, smoking?, COC use, late menarche (>16)

Most common symptom of fibroids?

Heavy, prolonged menstrual bleeding

Other symptoms of fibroids?

Pelvic pressure/pain, constipation, urinary issues, low back pain, dyspareunia, ↓ fertility

Pharmacologic options for heavy menstrual bleeding in fibroids?

LNG-IUS (preferred), COC, NSAIDs, tranexamic acid (limited evidence).

What drugs can reduce fibroid size?

Danazol; GnRH agonists (temporarily; size may return after stopping)

Time limit for GnRH antagonists in fibroid therapy?

Max 24 months due to risk of irreversible bone loss

What is the first drug used in the mifepristone/misoprostol regimen?

Mifepristone

MOA of mifepristone?

Progesterone receptor blocker → destabilizes endometrium, softens cervix, increases uterine sensitivity → enables termination

MOA of misoprostol?

PGE₁ analog → uterine contractions + cervical ripening; also increases gastric mucus & reduces acid

Recommended regimen and effectiveness?

200 mg mifepristone PO → 24h later 800 mcg misoprostol buccally; 96% effective up to 63 days gestation

Absolute contraindications to medical abortion?

Ectopic pregnancy, chronic adrenal failure, severe uncontrolled asthma, ambivalence.

Relative contraindications?

Unconfirmed gestational age, IUD in place, long-term steroids, bleeding disorders/anticoagulants, anemia (Hgb <95)

Drugs that may reduce effectiveness of medical abortion?

Carbamazepine, phenytoin, rifampin.Drugs increased by mifepristone: statins, benzos, amiodarone, tacrolimus, cyclosporine.

Expected bleeding after misoprostol?

Begins 1–48h after dose, heavier than menses, lasts 10–16 days; light bleeding up to 30 days. No tampons.

Common SEs of misoprostol?

Pain/cramping, N/V/D, dizziness, headache; fainting, breast tenderness, prolonged bleeding. Rare: arrhythmia, hemorrhagic shock, infection.

When should a patient seek urgent care?

Bleeding ≥2 pads/hour ×2 hours, bleeding >16 days, foul discharge, dizziness, fever >38°C >6h, feeling unwell >24h after miso

When does fertility return after medical abortion?

As early as 8 days.

Follow-up timing?

7–14 days with prescriber; pharmacist f/u at 2–3 days.

When can combined hormonal contraceptives (COCs, patch, ring) be started after medical abortion?

Immediately after misoprostol or once bleeding is manageable.

Why are COCs a good option after medical abortion?

They regulate cycles, reduce heavy bleeding, and provide immediate contraceptive protectio

When do COCs become fully effective post-abortion?

After 7 days; use backup method until then

When can progestin-only pills be started after medical abortion?

Immediately, including same day as misoprostol.

When is the progestin-only pill fully effective post-abortion

After 48 hours.

When can Depo-Provera (DMPA) be given after medical abortion?

Immediately, including at the time of mifepristone or misoprostol

How quickly does Depo-Provera work post-abortion?

It is immediately effective if given ≤7 days post-abortion; otherwise needs 7 days of backup.

When can an IUD be inserted after medical abortion?

Once pregnancy expulsion is confirmed, typically at the 7–14 day follow-up

Why not place an IUD immediately after misoprostol?

Risk of incomplete abortion and higher expulsion risk.