Lecture 63: Endometriosis and PCOS

What is endometriosis?

A condition where endometrium cells grow outside the uterus, affecting various organs such as ovaries, fallopian tubes, bowel, bladder and even the lungs

Oestrogen that causes proliferation in endometrial lining occurs elsewhere

What are some symptoms of endometriosis?

Painful cramps, painful bowel movements/urination, pain during/after sex, fatigue, bleeding/spotting between periods, stomach/GI problems

What is the cause/contributors to endometriosis?

Exact cause not well understood

Mediated by hormonal fluctuations during normal menstrual cycle

Suggested causes: genetic predisposition, retrograde menstruation, abnormal tissue differentiation and immune dysfunction

What are the parts that make up the female reproductive system?

Ovary, ovarian ligament, endometrium, cervix, fallopian tubes, uterus, vagina

What are the risk factors of endometriosis?

Family history (1st degree relative), white, anatomical abnormalities, 1st pregnancy >30 years old, abnormal menstrual cycle, exposure to toxins

What are the tests needed to diagnose endometriosis?

Definitive is through laparoscopy

Other tests: ultrasound, MRI, physical examination

Blood tests and internal examinations are not conclusive

What is the overview of management of endometriosis?

Varies between patients, depends on age, needs, personal preferences

May involve limiting/stopping oestrogen due to proliferative effects

COCs not licensed for this but frequently prescribed off-label for symptom management

What are the pharmacological options for endometriosis?

Analgesics (e.g. mefenamic acid, naproxen, ibuprofen) to help pain modulation - consider short-term paracetamol+NSAID

POC (progesterone only contraceptive) can help keep oestrogen levels low

Gonadotrophin-releasing hormone (GnRH)

What are the non-pharmacological management strategies for endometriosis?

Heat packs/warm baths/hot water bottles

TENS machine - electric signals to provide pain relief by blocking pain signals/increasing endorphin production

Physiotherapy

What are the main complications associated with endometriosis?

Sub-fertility - can make it more difficult to get pregnant although infertility is uncommon

Recurrence - symptoms will recur in 20-50% of patients following surgery/medical intervention

What is adenomyosis?

A condition where endometrial tissue grows into the muscular wall of the womb

Cells behave in the same way as a normal menstrual cycle and build up, resulting in thickening of the wall overtime

• More likely to cause heavier bleeding than endometriosis

• May also be asymptomatic

How does adenomyosis contrast to endometriosis?

Unlike endometriosis where endo-tissue is found outside uterus lining, adenomyosis is caused by these cells moving deeper into the uterus lining, into muscle layer

What is polycystic ovary syndrome (PCOS)?

An endocrine disorder that occurs when the ovaries produce higher-than-normal levels of androgens (“male hormones”), which disrupt the normal menstrual cycle and ovulation

What can PCOS cause?

Leading to irregular menstrual cycles, difficulty ovulating and other metabolic issues

How does hyperinsulinaemia contribute to PCOS?

Increases ovarian androgen production and enhances the effect of LH, leading to higher levels of male hormones

How do increased LH and insulin affect testosterone levels in PCOS?

Increased LH stimulates androgen production, while high insulin increases free testosterone by reducing sex hormone binding globulin (SHBG)

Why does ovulation not occur in PCOS?

Excess androgens disrupt normal follicle development, preventing ovulation and causing follicles to become arrested and form cysts

Why is oestrogen present but progesterone low in PCOS?

Androgens are converted to oestrogen in adipose tissue, producing continuous oestrogen, but progesterone is low because ovulation does not occur

What is the diagnostic criteria for PCOS?

Confirmed through specific diagnostic criteria - if a person has 2 of the following:

• Ovulatory dysfunction

• Signs of hyperandrogenism - acne, excessive hair growth (hirsutism), elevated testosterone

• Polycystic ovarian morphology on ultrasound

Perform ultrasound to rule out differential diagnoses

What blood tests are performed when PCOS is suspected?

Total testosterone (usually elevated), sex-hormone binding globulin, calculate free androgen index, LH/FSH

What are the complications of PCOS?

Increased risk of T2DM, pregnancy complications, endometrial cancer and CVD risk

Psychological disorder

Infertility (most common cause)

What is involved in the management of PCOS?

Educate on healthy living/behaviours e.g. weight loss

Use of COC

• Helps regulate irregular ovulation patterns, lowers testosterone and therefore, hyperandrogenism

• Provides endometrial protection

Manage acne

Manage hirsutism

Metformin off label use?

What is your role as the pharmacist in terms of patients with PCOS?

Information regarding pain management

Explain how to take/use hormonal contraception safely

Advise/educate about possible long-term complications of PCOS

Encourage healthy lifestyle

Manage symptoms in the pharmacy e.g. acne

Signpost for further support/advice