Endometriosis

Snapshot

A 29-year-old nulligravida presents to her gynecologist for severe pain with menses and inability to conceive after 2 years of unprotected intercourse. She says she feels pain with defecation and intercourse. On pelvic exam, her uterus is found to be retroverted, and there is nodularity of the uterosacral ligament on retrovaginal examination.

Introduction

Overview
- a nonmalignant condition where endometrial glands and stroma are located outside of the uterus
Epidemiology
- incidence
  - 7-10% of women in the US
- demographics
  - only in female
  - most commonly in those 25-29 years of age
- location
  - ovaries (most common)
  - uterosacral ligaments
  - retrouterine pouch (pouch of Douglas)
  - peritoneum
- risk factors
  - family history
  - early menarche
  - nulliparity
Pathophysiology
- pathobiology
  - ectopic endometrial tissue leads to an estrogen-stimulated inflammatory response
Associated conditions
- chronic pelvic pain
- endometrioma (“chocolate cyst”)
  - endometriosis affecting the ovary
- subfertility
Prognosis
- natural history of disease
endometriosis may self-stabilize without treatment; however, this may be a progressive, relapsing, or chronic condition

Presentation

Symptoms
- dysmenorrhea
- dyspareunia (painful intercourse)
- dyschezia (painful defecation)
- infertility
- chronic pelvic pain
Physical exam
- nodular thickening of the uterosacral ligament
- a fixed retroverted uterus
tender, fixed adnexal masses

Imaging

Studies

Seurm labs
- may be associated with increased CA-125 levels
Laparoscopic visualization with histologic confirmation
- provides definitive diagnosis of endometriosis
- classically may see “powder burn” appearance
Histology
endometrial glandular tissue

Differential

Treatment

Conservative
- observation
  - indication
    - for patients with asymptomatic endometriosis that is discovered incidentally
Medical
- combined hormonal or progestin-only contraceptives
  - indications
    - considered first-line for pain due to endometriosis
- gonadotropin-releasing hormone (GnRH) agonist
  - indications
    - second-line treatment for endometriosis
  - mechanism
    - inhibits gonadotropin secretion which
      - decreases FSH and LH levels leading to a suppression of ovarian function
- levonorgestrel-releasing intrauterine device (IUD)
  - indications
    - another second-line treatment for endometriosis
- danazol
  - indications
    - not commonly used due to side-effects
  - mechanism
    - suppreses FSH and LH pituitary secretion
Surgical
- laparoscopic ablation
  - indications
    - surgery is the only definitive treatment and diagnostic modality
- total abdominal hysterectomy with lysis of adhesions
  - indications
in patients who have completed childbearing with severe and recurrent disease

Complications