Obstetrics and Gynecology/Endometriosis

Definition Endometriosis is the ectopic location of endometrial tissue. This includes both stromal and glandular tissue. Endometriosis is known to occur at many varied sites. Epidemiology Endometriosis occurs in 7-12% of women. Endometriosis occurs in up to 50% of premenopausal women. Endometriosis occurs particularly in infertile women (~40%) and those with chronic pelvic pain (>70%). Note that there has been no ethnic linking to endometriosis. Etiology, Pathophysiology, and Risk Factors The pathophysiology of endometriosis is not well understood. However, several theories exist: Retrograde menstruation (NOTE: most endometriosis occurs in local pelvic sites accessible to retrograde menstruation) Immunodeficiency (limiting the clearance of transplanted tissue) Coelomic metaplasia (some factor induces the change of undifferentiated peritoneal cells into endometrial cells) Lymphatic flow from uterus to ovaries Hematogeneous spread to distant sites Risk factors for endometriosis Family history of endometriosis Obesity (potential estrogen link) Chronic pelvic pain Infertility Clinical Presentation and Diagnostic Approach Many women with endometriosis are asymptomatic The classical triad of symptoms, however, are Dysmenorrhea (may be exaggerated or occurring before menses) Dyspareunia Infertility The endometriosis patient will likely have suffered from chronic pelvic pain Pain correlates well with the severity of lesions: this pain may extend well beyond the lesion sites Systemic involvement: for example, cyclic diarrhea with menses. Adenexal mass Low-level echoes on ultrasound Imaging should only be performed on the presence of an adenexal mass The diagnosis of endometriosis is made via Laparoscopy with biopsy and histology Both glandular and stromal tissue must be found for diagnosis to be made Management Can be divided into Medical or Surgical management Medical management of endometriosis Non-Hormonal NSAIDs Hormonal BCP/MPA DMPA Danazol GnRH analogues Surgical management of endometriosis Conservative: laparoscopic excision of lesions with restoration of normal anatomy, such as adhesiolysis, ablation of endometrial spot Radical: hysterectomy with bilateral salpingo-oophorectomy, if Hormonal replacement therapy is required, progesterone should be given otherwise the estrogen dependent endometrioma may grow on pelvic tissue.