Updated: 10/28/2019

Endometriosis

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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
  • Ultrasonography 
    • indications
      • first-line imaging modality to assess for endometriosis
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
  • Adenomyosis
    • differentiating factor
      • invasion of endometrial glands into uterine myometrium
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
  • Infertility
  • Ectopic pregnancy
 

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