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  • • Dysmenorrhea

    • Constant aching lower abdominal pain, beginning 2-7 days before the onset of menses, and increasing in severity until menstrual flow subsides

    • Clinical diagnosis is presumptive and must be confirmed in severe cases with laparoscopy or laparotomy

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Epidemiology

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  • • Prevalence in United States is 2% among fertile women and 3- to 4-fold greater in infertile women

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Symptoms and Signs

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  • • Lower abdominal pain

    • Infertility

    • Dyspareunia

    • Rectal pain with or without hematochezia when ectopic endometrial implants involve the rectum

    • Tender indurated nodules in the cul-de-sac (can appreciate best during menses)

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Laboratory Findings

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  • • β-hCG negative

    • UA normal

    • WBC count within normal range

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Imaging Findings

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  • US: Findings will often reveal complex fluid-filled masses that cannot be distinguished from neoplasms

    MRI: More sensitive and specific in diagnosing adnexal masses

    Barium enema: May delineate colonic involvement

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  • • Pelvic inflammatory disease

    • Uterine myomas

    • Ovarian neoplasms

    • Polycystic ovarian disease

    • Appendicitis

    • Acute enteritis

    • Ruptured corpus luteum cyst

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Rule Out

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  • • Ectopic pregnancy

    • Threatened abortion

    • Acute appendicitis

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  • • Thorough history and physical exam

    • Complete pelvic exam

    • β-hCG

    • Transvaginal US

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When to Admit

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  • • Significant abdominal pain and the diagnosis is uncertain

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  • • Goal is to ameliorate symptoms and preserve fertility

    • Mainstay of therapy is medical inhibition of ovulation

    • Laparoscopy/laparotomy to resect the lesions, free adhesions (with or without suspension of the uterus for patients younger than 35 to preserve reproductive function is controversial)

    • Foci of endometriosis can be treated laparoscopically by bipolar coagulation or laser vaporization

    • Hysterectomy with bilateral salpingo-oopherectomy for patients older than 35 with debilitating pain

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Surgery

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Indications

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  • • Definitive diagnosis via laparoscopy

    • Failure of medical management

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Medications

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  • • Gonadotropin-releasing hormone (GnRH) analogs

    • Danazol

    • Oral contraceptive pills

    • Medroxyprogesterone acetate

    • NSAIDs during menses

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Complications

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  • • Recurrent symptoms

    • Infertility

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Prognosis

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  • • Prognosis for reproductive function in mild or moderately advanced endometriosis is good with conservative management

    • Bilateral oopherectomy is curative in severely affected patients

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References

Hughes E et al: Ovulation suppression for endometriosis. Cochrane Database Syst Rev 2000;CD000155.
Lebovic DI et al: Immunobiology of endometriosis. Fertil Steril 2001;75:1.  [PubMed: 11163805]
Moore J et al: Modern combined oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2000;CD001019.

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