Endometriosis

• • 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

Epidemiology

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

Symptoms and Signs

• • 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)

Laboratory Findings

• • β-hCG negative

  • UA normal

  • WBC count within normal range

Imaging Findings

• • 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

• • Pelvic inflammatory disease

  • Uterine myomas

  • Ovarian neoplasms

  • Polycystic ovarian disease

  • Appendicitis

  • Acute enteritis

  • Ruptured corpus luteum cyst

Rule Out

• • Ectopic pregnancy

  • Threatened abortion

  • Acute appendicitis

• • Thorough history and physical exam

  • Complete pelvic exam

  • β-hCG

  • Transvaginal US

When to Admit

• • Significant abdominal pain and the diagnosis is uncertain

• • 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

Surgery

Indications

• • Definitive diagnosis via laparoscopy

  • Failure of medical management

Medications

• • Gonadotropin-releasing hormone (GnRH) analogs

  • Danazol

  • Oral contraceptive pills

  • Medroxyprogesterone acetate

  • NSAIDs during menses

Complications

• • Recurrent symptoms

  • Infertility

Prognosis

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

  • Bilateral oopherectomy is curative in severely affected patients

References