Obstetrics and Gynecology/Endometriosis

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Definition[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

Can be divided into Medical or Surgical management

Medical management of endometriosis


  • NSAIDs


  • 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.