Endometriosis is the implantation of endometrial tissue outside of the uterus, resulting in dysmenorrhea, dyspareunia, and infertility (along with location-specific symptoms). Diagnosis is through direct visualisation and treatment is ovarian suppression and surgery.
Pathophysiology
- Retrograde flow of menstrual tissue through the fallopian tube
- Endometrial cells implant ectopically
Contextual Factors
- 1st degree relatives with endometriosis
- Delayed childbearing or nulliparity
- Early menarche
- Late menopause
- Shortened menstrual cycles with heavy/ prolonged menses
Protective Factors
- Multiple births
- Prolonged lactation
- Late menarche
- Early menopause
- Long-term use of oral contraceptive pills
Clinical Manifestation
Classic Triad
- Dysmenorrhea: pain durring menses
- Dyspareunia: pain during intercourse
- Infertility
Location-Specific Symptoms
- Variable based on ectopic implant site
| Site | Symptoms |
|---|
| Ovaries | Endometrioma (2 - 10 cm cyst), abdominal pain, peritoneal signs |
| Adnexal structures | Adnexal adhesions, pelvic mass, pelvic pain |
| Bladder | Dysuria, hematuria, suprapubic/ pelvic pain, urinary frequency, urge incontinence |
| Colon | Defecation pain, bloating, diarrhea, constipation, rectal bleeding during menses |
| Extrapelvic structures | Vague abdominal pain |
Diagnosis
- Direct visualisation: pelvic laparoscopy, laparotomy, vaginal exam, sigmoidoscopy, cystoscopy
- Biopsy - not required but confirms diagnosis
- Up and coming: T1 and T2-weighted MRI
Staging
| Stage | Classification | Description |
|---|
| I | Minimal | Superficial implants |
| II | Mild | Deeper implants |
| III | Moderate | Deep implants, small endometriomas, filmy adhesions |
| IV | Severe | Many deep implants, large endometriomas, dense adhesions, rectal adhesion to uterus |
Treatment
Pharmacotherapy
- First line: Estrogen-progestin contraceptives
- Others: progestin, gonadotropin-releasing hormone agonists and antagonists, danazol
Surgical
- Surgical resection or ablation of endometriotic tissue
- Total abdominal hysterectomy w/ or w/o bilateral salpingo-oophorectomy
Supportive