Obstetrics and Gynecology/Endometriosis
Endometriosis is the ectopic location of endometrial tissue. This includes both stromal and glandular tissue. Endometriosis is known to occur at many varied sites.
- 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
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)
- 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
Can be divided into Medical or Surgical management
Medical management of endometriosis
- 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.