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CRF Endometriosis Dr Toni Hazell (31.01.23)

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Summary

This on-demand teaching session led by Dr. Tony Hazel focuses on endometriosis and its relevant impacts on medical professionals. The course looks at the causes of endometriosis, the symptoms associated with it, and how to diagnose and manage it. Through case studies and practical examples, participants will learn how to effectively assess, diagnose, and support those suffering from endometriosis. This session is highly relevant to medical professionals who see women with menstrual pain, fertility issues, and other endometriosis-related problems.
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Learning objectives

Learning Objectives: 1. Understand the definition, causes and associated risks of endometriosis 2. Identify key history information to take from a patient with suspected endometriosis 3. Recognise possible signs and symptoms of endometriosis on examination 4. Understand the importance of conducting a risk assessment when planning treatment and management strategies 5. Appreciate the implications of a normal ultrasound result for the diagnosis of endometriosis
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That. There we go. Fantastic. Hi there everyone. And so my name is Tony Hazel. I'm a GP in the UK with a particular interest in women's health. And I'm going to talk today about endometriosis. Um of necessity. Some of the, some of the slides are a bit UK specific as, you know, refer to our guidelines and so on. But I'll try and kind of broaden things wherever I can and that's my declaration of interests. Um So what is endometriosis? It's basically when endometrial tissue is found where it shouldn't be. So it should only be in the endometrium. Um So with endometriosis, you can find endometrial tissue in the myometrium, that's the wall of the uterus. And that's called adenomyosis or you can find it elsewhere in the pelvis. Uh for example, on the fallopian tubes, on the ovaries or the pouch of Douglas, um or you can find it more distantly. Um So it has been known for people's endometriosis to prevent with nosebleeds, for example, that, that go with their cycle because they've got endometriosis in the nose or rectal bleeding. If they've got endometriosis in the about, it's really common and it's strongly associated with sub fertility. Um So, although it's difficult to be certain of prevalence because not everyone reports symptoms. It's thought that if you take the population of women who attend a fertility clinic, then a third to a half of them will have endometriosis. And in the general population of women of reproductive ages, maybe 5 to 10% of women. Um There's been a lot of publicity in the UK lately about women's health and issues with women's health. And one of the figures that that goes around is that this figure that it takes 7.5 years from the onset of symptoms to get a diagnosis of endometriosis. And that this represents avoidable delay. And I suspect there's probably similar figures going around in other countries. And um whilst I don't dispute the actual length of time, it's not necessarily the case of all of that is avoidable delay. And we'll talk a bit more about thoughts about, you know, when uh for countries, whether it's primary care system, when endometriosis should be managing primary care when it needs to be referred. So, uh slide. So um what causes endometriosis? We don't really know. Um There's probably some genetic component, there's probably some immune dysfunction component, although there's been no specific gene identified and there's certainly nothing like any gene therapy. Um There is the retrograde menstruation theory, sorry, apologies. That's my clock going in the background. The retrograde menstruation theory is that endometry a lung tissue goes out through the fallopian tubes into the pelvis. But obviously, that can't explain more distance disease, um which could be explained by the theory of dissemination through the lymphatics. There's also the theory that that there might be metaplasia. So a spontaneous change of normal cells into the endometrial cells rather than them moving from the endometrium to elsewhere. Um But we, we don't really know, it's probably it may well be a mix of all of these things as is often the case. Um We do know that if you have more periods, you're at higher risk of endometriosis. So if you don't have Children or you've had them late or you have an early menarche, early data, started your periods or a late menopause. Um If there's a family history, if you're very thin, um if you have other autoimmune disease, if you smoke, if you have a later age of first sexual intercourse, and if you have some sort of vaginal outflow obstruction, um but I've got plenty of patients with endometriosis, you don't particularly have any of these risk factors. And this is this is the sort of thing that the press are printing in the UK. So what are the problems with having endometriosis? Well, it causes pain um and it can cause adhesions within the pelvis which obviously cause ongoing pain. You can get large endometriotic cysts, um which can also cause pain and a mass. As I said, it strongly associated with sub fertility can occasionally cause bowel obstruction and certainly has been shown as with many other chronic medical conditions to be associated with a reduced quality of life. So, let's have a case study. Let's meet Aurora. So she's 17 and she's come to see you with her mum and as is common, you know, mom's kind of dragging her in through the door and she's just sitting there looking at her shoes and looking extremely embarrassed and she's there because, um, she goes to college and they've raised concerns that she is missing college every single month due to period pains. And this has come to a head because her next period is due during some important exams. Um, she's had her period for about four years but she's only had this pain for about a year. Um, so have a think, um, about what else you might want to know. In fact, I could open it up. Does anyone want to a mute or put in the chat? Anything that they might ask aurora when they were taking a history? I know it's tricky sometimes with timing. Hello there. Timing, timing, timing of the pain. Absolutely. So, does it, does it start before the periods or just during, does it only last for the first couple of days or does it last longer or is the pain actually now becoming all month? Very good anyone else? Uh, but also like, uh, ask the mother to leave the room and ask her some more intimate questions the, to the child, whether she has been sexually active or not. Yeah. Absolutely. Very important. Absolutely vital that you see a roar on her own. And I usually just say to mum standard for girls, for people this age that I always see them alone as well as with their parent. Do you mind having a seat in the waiting room? And the parent doesn't generally mind. And in fact, if a parent really did object, then that would be a potentially sort of safeguarding kind of child protection issue if they wouldn't leave the room. Um, okay. So the nature of the period until for how often she's changing her, uh, you know, sanitary and Afghan is heavy. Yeah. Is it like very true? How heavy is? So when I have people with heavy periods are really try and quantify, you know, questions like, do you have to set an alarm for the middle of the night to change your protection? Do you use tampons or pads? Do you ever use both? Do you ever flood through them? Absolutely. Ok. General health as such. Yeah. Yeah. Yeah. General health because, um, she, you might think about using the combined pill to treat this. So, you know, she's 17, most 17 year olds don't have many health conditions, but she could have a migraine with aura which would contraindicate the pill or she could have a big strong family history. Of blood clots which would contraindicate the pill. Absolutely. Anyone else, any recent activities? Uh, not the intermittent but the other activities. Is it, uh, or state of the state of emotions? Yeah. Absolutely. How's this affecting her psychologically? And I guess what is the pain stopping her doing? You know, is issue, managing to kind of, we already know it's stopping her going to college. Is it stopping her doing anything else sport or any other activities? Okay. Great. I'll move on. So, um, endometriosis tends to prevent with pelvic pain, dysmenorrhea, which persists through the whole cycle. Um, if she's sexually active, she might have pain during sex, she might have cyclical dyschezia, which is the word for pain when you open your bowels. If she's got endometriosis in the, um, in the bowel or symptoms at distal sites, um, as I mentioned nosebleeds before. If you have deposits of endometrium under the diaphragm, you can get shoulder tip pain during the period. That's a very specific symptom, she might be tired, you know, being in pain is tiring and if her periods are heavy, she might be anemic. And then on examination, um, it's really important to realize that the examination might be entirely normal and that does not exclude endometriosis, but you might notice tenderness if she was sexually active and you did a vaginal examination, you might find an actual mass or that the, the uterus was retroverted and fixed, which would suggest adhesions. If you did a speculum, you might see visible lesions in the vagina which tend to look at a dark bluish kind of color. And you certainly want to ask about the impact on her life and her work and education and signpost to support. We have a very good charity Endometriosis UK in this country, but whatever your local support systems are, and as has been said, you'd want to get her on her own and advise her, um, find out she was sexually active, obviously advising her that, you know, her confidentiality is assured unless there are any significant concerns about safeguarding. So, if she sexually active, does she need contraception, is she trying to conceive unusual at 17 but not unheard of. Does she have any unusual bleeding such as in between her periods into menstrual bleeding or after sex, postcoital bleeding, any symptoms of a sexually transmitted infection? And is she, is she at risk of it if she is sexually active? Does she use condoms? Has she ever been pregnant before again? Um, you know, you might need to get mom out of the room to find out if she's had a termination or something that her mom doesn't, doesn't know about what has she tried. So, has she tried painkillers over the counter or has she ever seen a doctor about this before? Um, any contraindications, as I said to the pill, um, any family history of endometriosis? And has she kept any sort of diary. It's increasingly common now for women to use apps to track their periods. So you may actually find that there's a lot of information there, particularly, she has marked the days that she has pain. Um So, apologies, Aurora seems to have morphed into Lauren, that was from a different talk. So you manage aurora, examine aurora and everything's normal and you request an ultrasound which comes back normal. Um So, um I've pretty much said this already normal examination and a normal scan does not rule out endometriosis. And that's really important and it's important to sort of manage expectations at the start. I often find that patient's are disappointed when a test comes back normal, which seems strange. You know, you should be happy, but it's because they think that you're dismissing their symptoms, your test is normal means your symptoms don't matter or you're not telling the truth. And obviously, that's not the case you might find on a scan and endometriotic cyst or something that some fluid in the pouch of Douglas. But it's quite common for a scan to be normal in endometriosis. So I just thought it was worth talking about the two types of dysmenorrhea, period, pain says primary dysmenorrhea, which is that, that has no cause. It's just idiopathic. Um, it's probably caused by uterine prostaglandins in menstruation causing cramps and it's fairly typical. It normally starts quite soon after the onset of the period. So, within 6 to 12 months and the pain starts before the period a day or two before and it only lasts for up to three days. He might feel a bit tired or a bit sick and have a bit of pack pain and it can be treated over the counter or we can treat it with things like hormonal contraception or an entry. You try and device. Um This is different from secondary dysmenorrhea, which is pain that is caused by an underlying pathology. Be it endometriosis, fibroids and adnexa, all mass pelvic inflammatory disease. Um And often in this case, the story will be that the first few years of the periods were fine, no pain or very minor pain and then pay pain started a bit later. It usually carries on for longer. So it will carry on during the whole period or possibly a few days afterwards and then over time it progresses so that, you know, a woman who is presenting with this maybe in her twenties or thirties and has never sought help might have got to the point where actually she's got pain all month than it's just worse during the period. It might be associated with pain during intercourse, very heavy bleeding or bleeding in between the periods or after sex. And obviously, management involves making the diagnosis and then treating the underlying cause rather than just treating the symptoms. So, um what are we going to find have touched on some of this already? These are what you might find on examination or on um scan. But as I said, a normal examination and normal scan does not rule out endometriosis and that's really important. So this talk is called endometriosis. So clearly, that's what the patient's going to have. But in real life, we start from a symptom rather than a diagnosis. So there's all sorts of differential diagnoses here um from primary dysmenorrhea, which can just be managed symptomatically through fibroids, which again are often managed just by treating the symptoms rather than surgically. Um, an acute pain might indicate pelvic inflammatory disease or indeed, a chronic pain could be chronic infection. Um Don't forget that women's pelvis is also contain organs from other organ systems. So think about the bladder and the bowel. She could have something like intestinal cystitis or a chronic or recurrent urine infections. An ovarian cyst not related to endometriosis at 17, it's pretty unlikely that aurora is going to have cancer, but, you know, you always need to consider it, have it at the back of your mind. And certainly if it was an older woman, uh complaining of new pain, particularly sort of pain and a bloating feeling in an older woman, uh, you need to think about, about ovarian cancer. Um Is she pregnant? Could it be just normal aches and pains during pregnancy or could it be an ectopic? Does she have some sort of gastroenterology, gastroenterological system, pain or musculoskeletal pain or has she got something rare and congenital. So there's a lot of, a lot of differential diagnosis to think of and as with everything we're using our history and examination test, sort of a detective thing to, to rule things out as we go along and try and get to the right diagnosis. So we've heard that her pain started a few years after the menarche, which immediately makes you think about secondary dysmenorrhea rather than primary it lasts for the whole period. And when you specifically asked, she says that, yeah, actually when I go to the toilet do apu it's a bit hurts a bit when I'm on my period and not the rest of the month, she's not sexually active and she's healthy with no contraindications to the combined pill and she's bought a bit of paracetamol and ibuprofen over the counter, which has helped a bit. She says it's sort of taken the edge off the pain but hasn't got rid of it and hasn't tried anything else. So options. So we could treat her with either the combined pill or the progesterone only pill. We could refer her to gynecology and wait or we could refer her to gynecology and treat while she's waiting to be seen. And any of these would be good apart from the third one. So there's absolutely no reason to leave her in pain from primary care. We should be treating this particularly because it might be a while till she gets to see gynecology. The UK guidelines say that we should consider referring women if they have severe persistent or recurrent symptoms or they have pelvic signs or if initial management is not effective, not tolerated or contra indicated. Um Now, most of the things that we would initially manage endometriosis within primary care are also contraceptive. So any woman who is trying to conceive, probably need referral. Um And obviously, if he's tried a bit of management in primary care and it's not working, then they need referral. So what could we do? Well, she's tried painkillers over the counter. We could step those up. So she's tried Ibuprofen, which is available over the counter. We could maybe give her some naproxen, which is prescription only. Um We could try a neuromodulator like gabapentin or amitriptyline. But for someone of her age, I would generally go straight into trying to stop her ovulating. Um So I would usually start with the combined pill taking back to back, but she could have the progesterone only pill if she had a contra indication to estrogen or if the combined pill gave her side effect and she could also have the depo Provera or other progestin's prescribe continuously. Um The Mirena intrauterine system is very good for treating endometriosis. Um and, and it also provides contraception, you can fit it in teenagers. It probably wouldn't be my first line for a 17 year old who's never had sex. And if she is taking the pill, then I would definitely want to consider an extended pill taking regime. So when the combined pill first came on the scene in the 19 sixties, I think it's easy for us to get just how controversial it was for women to be taking control of their own fertility. And it was quite controversial with organizations like the church and it was designed to mimic a normal cycle. So you have three weeks worth of pills in a packet and you take three weeks and then you stopped for a week during which you get your period. But there is no medical or contraceptive reason why that the woman has to have a bleed every month. It's a nuisance. And um it is actually that the pill free interval is the point at which the pill is at highest risk of failing. So a woman who's taking the pill, the combined pill for contraception is still protected during that seven day um interval. She doesn't have to use condoms or anything like that. But we know that women vary in how fast they metabolize estrogen. And there is a group who are called ultra fast metabolizers for whom at the end of a seven day break, they will be perilously close to having their estrogen level fall to the point at which they might ovulate. And certainly if they forget to start taking the pill again and they have an eight or a nine day break, then they are at risk of pregnancy. I think this is often quite poorly understood. If you say to a woman on the pill, which is more risky, missing a couple of pills in the middle of the packet or starting a packet late. They will usually say that missing pills in the middle of a packet is more risky, but actually, that's a very low risk thing to do. Whereas starting a packet late. So you've had eight or nine day break is much more risky for getting pregnant. So I pretty much never whether I'm prescribing the pill for contraception or for another reason, such as endometriosis, I pretty much never prescribe three weeks on seven days off anymore. I can't remember the last time I've done that. If a woman wants to have a break every month and wants to bleed every month, then I would suggest a four day break because obviously that's less time for the estrogen levels to fall for those fast metabolizers. And it means that if she is a day or two late in starting, she's still within the original week of the, of the normal regime. But what I suggest for most women is why don't you take two or three packets in a row and then have a four day break? Do you only have to have a break every six or nine weeks? Which is less hassle? And of course, the nice thing about the pill is that if you are innocent situation where you really don't want to have a period. Like you're going away on a beach holiday or trekking in a remote location, you can just run more packets together. Every woman is different in terms of how much they're endometrium will take before they start bleeding. Some women can take three or four or six or even longer months of the pill without having any bleeding. Some will start to bleed after they run together a couple of packets. And so these sort of the, the other options are flexible extended use where you just take it and you take it and you take it and you keep taking it until you bleed. And when you have a breakthrough bleed, you stop for four days and then you carry on and continuous use is just you take it, you keep taking it whether or not you're having a bleed and you probably have a small bleed every now and then. But you keep taking it continuously and this images from the Faculty of Sexual and Reproductive Health, which is in the UK, the gold standard for UK guidelines in this area. So it's perfectly defensible to prescribe the pill like that even though it is outside of the product license. So um uh the only way to um diagnose endometriosis is with the laparoscopy. And this comes back to what I was saying earlier about about this 7.5 year delay thing. Aurora 17, she's at college, you can treat this in primary care. It's perfectly reasonable that she might not want to be referred for an invasive surgical procedure. But if you don't mention to her now, the possibility of endometriosis and she comes back in 10 years time when maybe she's wanting to get pregnant and has to come off the pill and then he's diagnosed, she's going to say hang on a second. I came to see you 10 years ago. Why didn't you diagnosed me then? So what I usually do is discuss with the patient if they want referral and mention the word endometriosis, document my suspicions in the notes so that if they choose not to be referred, which might be perfectly reasonable, at least you know that you were thinking about it and you've told them. So you decide, um, as she doesn't want to be referred, you treat her with the combined pill on an extended pill taking regime. She comes about three months later. She's absolutely thrilled because she hasn't had a period and you say that's great. Go away. Keep going. We need a BP in a weight once a year and you know, come back and see us if there are any problems and you don't see her for 10 years. She's now 27 she wants to get pregnant. So she's come off the pill and unsurprisingly all her symptoms have come back and they seem to be worse and she doesn't really know what to do. So, any ideas, what would you do at this point? Okay. Well, what I would do, obviously it depends what, what situation you're in. But I would refer her to gynecology because I have very little to offer her. Everything that I have to offer her in primary care, apart from normal painkillers is contraceptive and she wants to get pregnant. So that's no good. So you referred to gynecology and she decides to go back on the pill while she's waiting and then she has a laproscopy and endometriosis is confirmed. So it's really important that we make sure that we refer to the correct specialists. And obviously, this is UK specifics in the UK, we have a list of recognised endometriosis um specialist centers. And so any patient with complex endometriosis must be seen at a specialist center. I'm lucky I work in London or my local hospitals, a specialist center. So I don't have a decision to make. Obviously, if you're somewhere very ruhr away, and you might refer to a sort of more normal, you know, normal hospital if that's your local one and then on to a specialist center if needed. But the point of a specialist center and this is relevant, whatever healthcare system you work in is that it will have a multidisciplinary approach. So as well as Gynaecologists, the team would include your urologists and colorectal surgeons so that they can deal surgically with bladder or bowel endometriosis and they would be able to get in the surgical expertise if needed. It should have a pain clinic that understands pelvic pain. Um It should have a nurse specialist, endometriosis nurses, it should have psychology. Um and it should have fertility specialists and all of these should be able to see the patient. So you've got really a true multidisciplinary approach and obviously, I would always treat while the patient's waiting to be seen. The gold standard is laproscopy is the only way you can truly diagnose endometriosis. So I might have my suspicions raised by a scan. If for example, the scan reported appearances of the myometrium that would consistent with adenomyosis or if there was a big cyst that looked like it might be an endometriotic cyst or if there was fluid in the pouch of Douglas. But laproscopy is the only way to 100% diagnose it. And of of course, it allows treatment as well. So usually the gynecologist will get consent for treatment if it is found before the procedure um to the deposits can be excised. Uh adhesions can be, can be divided um use laser and things. And if there are big endometriotic cysts, they can be removed usually very carefully. They are generally full of sort of fluid containing endometriotic cells. And if you burst them, then obviously, that's a bit of a disaster because the fluid goes all over the pelvis. Um I have actually seen a cyst sort of removed, put into a little bag and then burst within the bag and removed. Absolutely amazing in credible surgical skills these people have. So, aurora has her endometriosis treated during her laproscopy and she comes off the pill and six months later, she's not pregnant. Um So I probably won't ask this because it does depend on what system you work. But certainly I would refer her to a fertility clinic at this point. So, um in the UK, we generally consider that we would start to think about investigation and referral of women and their partners when they've been trying to conceive for a year and haven't got pregnant. But if they have a known reason why it might be more difficult such as they're older than 35 or they've got endometriosis or they've got Polycystic ovaries or they've only got one fallopian tube or some other reason, then you would usually refer after six months because they're much more likely to need help. So at this point, don't forget your preconception advice, make sure she's not smoking, make sure she's taking her folic acid. Um, she's otherwise healthy, but you've got to think about a woman sort of in the round, everything that's going on. So, if women are on medication for any other medical conditions and you have to think about is that teratogenic, do they need a referral with their specialist? If they are overweight? If they have a BM I over 30. So they fall into the obese category, then they need to take a higher dose of folic acid. And there's various other groups of people who need a higher dose or folic acid. So you do all the initial work up from her and her partner, you refer her to the clinic and she has two successful pregnancies are, are fantastic. And then afterwards she has an interview drawing system fitted, but it doesn't really work and she doesn't want to take the pill long time, long term. And she's done with her clinic with her, with her family. She says two kids is plenty. She can't imagine how anyone manages with more and she wants to be referred for hysterectomy. So this is quite a common request for lots of women's health problems, endometriosis, fibroids, heavy periods that often comes a time in a woman's life where they've tried everything and they're just like, you know what I'm done with happening my family, what do I need my uterus for? It's, it's only causing me problems. Can you just get them to take the whole lot out? Um Which is certainly a consideration. But obviously, hysterectomy is still significant surgery even if it can sometimes be done laparoscopically, laparoscopically. Um So an issue with the hysterectomy for endometriosis is of course, it might not solve the problem. So if or most of her endometriotic deposits are either in the myometrium or on the outside of the uterus, then yes, it might help. But if it's elsewhere, then it might not so that the counseling and the consent is really important here. Um And this is a guidance from nice, which is that if you are taking out the uterus, obviously, at the same time, you need to treat all other endometriotic lesion's. And from the European society of human re production and embryology, that it's a reasonable option in women who no longer want to conceive and haven't responded to other methods. But women should be informed that hysterectomy will not necessarily cure the disease. So we just need to manage her expectations. And then finally, I'm going to talk about H R T post endometriosis. So generally speaking, if a woman has HRT, when we're making the very early decisions about what kind of HRT that's hormone replacement therapy for the menopause, what kind of HRT she needs? There are two types, there's progest rogen and estrogen and there's estrogen only. So it is the estrogen that treats the symptoms of the menopause. Menopausal symptoms are due to the fall in estrogen. But if you give a woman who still has her uterus estrogen on its own, then over time, the endometrial will proliferate. You'll get endometrial hyperplasia and potentially endometrial cancer. And so for women who have had their uterus who still have their uterus, they get estrogen and a progestin gin and women who have had a hysterectomy, they get estrogen only. But if the woman has had her hysterectomy for endometriosis, then you need to be careful because if there are endometriotic deposits still left elsewhere in the body, then they could proliferate um with under, under pressure from the estrogen that you're going to give her for H R T. So, um I would usually in this case make contact with the gynecologist who did the operation and get their advice as to how many deposits they were left behind. Um And usually we would start with combined HRT and, and, and see where we go from there. Um And other groups of women for whom you need to be careful because the H R T decisions aren't that obvious are women who have had a sub total hysterectomy to the cervix has been left behind or women who have had an endometrial ablation for heavy periods for whom you would think it reasonable to prescribe estrogen only HRT because they're, they're endometrium or gone. But actually, there's always going to be some left. So they should always have combined HRT as well. So final few slides, these are the nice quality standards that women, all women should have an abdominal examination if they're presenting with symptoms of endometriosis and some if appropriate should have a pelvic examination. I wouldn't generally do a pelvic examination. Someone who's never had sex that if initial treatment is not effective tolerated or if it's contraindicated, women need referral and if they have complex endometriosis such as deep endometriosis involving the other organs and they need to be referred to a specialist service. So in summary, this is a common condition which you may not for which you may not get a definitive diagnosis when the first person first presents because it might be perfectly reasonable for you to treat them in primary care without referring. But it is important to mention it, mention your suspicions and document it in the notes. Consider a menstrual diary to record symptoms and always ask the woman if she's tracking them on an app. Remember that a normal examination scan doesn't rule it out and tell the woman that before you send her for a scan because otherwise scan comes in your busy, you mark it as normal without thinking who she is. She rings up, she speaks to reception, they say, oh, your scan was all normal and she'll be like, well, what now it's always remember, tell her that scan being normal doesn't rule it out and make a plan for follow up after the investigation, start treatment as early as possible. So don't delay for a definitive diagnosis even if you are referring and always off the psychological support and signpost to whatever support groups you have locally and that's it. So just over half now. So if anyone has any questions about this or about any other sort of women's health stuff in general, then I'm more than happy to answer them As'ad, yes, it was regarding the endometrial endometriosis itself that uh the inner lining of the endometrium, like the tissue qualif rates inside the myometrium. And uh it can go outside as like uh away, like from the, through the felon to you, but it can, could go outside the reproductive organ system, not being like externally but internally. Yeah. Absolutely. So you can find it all over the pelvis um and sort of spreading through the pelvis kind of up towards the diaphragm or it can be in more, in more distance. So maximum bridge it could go to lungs and like uh yeah, it can go to lungs. It's been found in the nose causing nosebleeds. You can go pretty much anywhere. It's been found in the brain. And this, in this case, it would be said that this is a classical form of endometriosis. Okay. Yes. So, so this case, she sort of, she, she had it in the pelvis and, and she was saying she had some pain on defecation. So she might have had it in the bow, but you can have it more deeply. So, any I, I guess one of the take home message is, is any bleeding in any cyclical bleeding in a woman of reproductive age. So it's always worth asking if someone comes in with say hemoptysis, iss, you know, blood when they're coughing, then it's always just worth checking. Does it have any relationship to your cycle? I think endemic distant endometriosis is not that common. I'm not aware of having seen a case ever and I've been a GP for 18 years but it does happen. But the thing is, uh, if the endometriosis is the, the inner lining of the endometriosis, endometriosis spreading so much, why we call it, uh, endometriosis? Why can't we call it the benign or the malignant form of, uh, cancer? I guess. I guess you could, it does, it does sort of spread like a cancer but, but it's not, I think the minute you weren't, you use the word cancer, people think malignancy. But yeah, there's, I guess there's an, there's an argument for, for looking at the naming. Thank you. I have a question. Hi, Chrissy. Hi. I'm just going slightly away from the endometriosis itself. Um, uh, you know, being a women and fertility is so important and having period issue from the young age is going to cause lots, lots of taboo uh, with certain culture. Definitely in my culture, I suppose, um, uh, you know, not being able to have Children is going to cause devastating effect on them in future, having marriage and, you know, family, how do we deal with this? And, you know, I'm sure you would have seen different cultures and, you know, we would have dealt with issues. Not only, you know, uh Asians or any other people. Do. We have to start talking about fertility issue from the beginning itself or alarm them causing them you know, depressions and things like that or is it something we can put it behind as much as possible? How does it possible, how is it going to be? I think it's difficult. I mean, I absolutely take your point about cultures. I work in a very multicultural area of London. So we have people from all sorts of cultures. Um I'm thinking of a patient at the moment who I have, who is newly married in her early forties from an African culture and who is very clear that if she can't give her husband a baby, we'll leave her. Now. I don't know how true that is, but she feels she's, she's very clear. This is my culture. I must give my husband a baby. Um And obviously, you know, even without any, any endometriosis or ever in your early forties, it's harder. So, um I usually, if I'm, if I'm considering endometriosis as a diagnosis, I do generally mention fertility at the start just because um I think otherwise they'll go away and Google it and, and get very stressed. So what I would usually say if I had a teenager or young adult who was not trying to conceive at the moment, it's not really on their radar. I'd say. So, look, you know, you do need to be aware that endometriosis affects fertility. On average, it will probably take you longer than average to get pregnant, but you may be able to get pregnant on your own. So don't use that as a reason not to use any contraception because I have arranged so many terminations of pregnancy for women who had some sort of gynecological condition. And when the doctor had told them it might take them a bit longer to get pregnant, they heard you're infertile, you can't get pregnant. So they went and had lots of unprotected sex and then end up with an unwanted pregnancy. So I usually say, might take a bit longer, still need to use contraception if you don't want to get pregnant. And in this case, you're probably going to be using it to treat the endometriosis anyway. Um and when you get to the point in your life where you want to try and conceive, then if you have not conceived after six months come and see us and tell us about it. And I point out that things that can help with conceptions such as staying a healthy weight, not smoking, not drinking to access, you know, all those sorts of things and, and those sorts of things are sometimes criteria for referral to fertility services in terms of managing people's emotions if, if they get to the end of that fertility sort of journey and they still can't get pregnant and, and there are cultural expectations. It's very difficult. I don't, I don't think I have an answer sometimes involving sort of local support groups which are culture specific can help, but sometimes it can be worse because she would just get a lot of pressure, um, to conceive. Obviously, there is adoption, there is surrogacy, but neither of those are straightforward at all. You know, there are certainly in the UK, there are very few babies available for adoption. Children who are available for adoption and usually older often have significant problems. Surrogacy is fraught with, with issues and, and has a, you know, sort of, and sometimes a confused legal status. So, yeah, I think, I guess it's just about using our consultation skills generally and making sure that we're always thinking about the woman and her family as a whole person rather than just the organ specific disease. Yes. Thank you. You're welcome. Any other questions at all? You're welcome to put them in the chat if you're uh what if the symptoms of endometriosis show while or after a while pregnancy? I mean, it's not, it's not necessary that it would show before the pregnancy before they want to get pregnant while the pregnancy. Sorry, I didn't quite hear that. Say that again. What of the endometriosis issue of the incident? Uh might not be like uh like uh it won't be coming to attention. But what if the endometriosis happens while the pregnancy while there we minister you generally. So you're not having a menstrual cycle when you're pregnant. So it would be unusual for symptoms to happen during pregnancy for the first time. Although I guess if you had, you know, if you had significant endometriosis causing an adhesion or something, but you'd expect that to have come first. So, it's, it's, that would be, that would be unusual. You'd be wanting to look for other causes of pain during pregnancy. Okay. I think that is probably it. Then I'll send you my slides. Hannah, if you want to um distribute them. But if no one has any more questions, I will let you have a coffee break before your next election. Thank you very much doctor before everyone leaves. Can I please remind you all to do the feedback form quickly? It just takes about two minutes. Um And after that, I will post the certificate in the chat. Okay. Thanks everyone. Bye. Thank you very much. Okay.