Endometriosis

Key Features

Essentials of Diagnosis

• Dysmenorrhea

• Dyspareunia

• Infertility (increased frequency)

• Abnormal uterine bleeding

General Considerations

• An aberrant growth of endometrium outside the uterus, particularly in the dependent parts of the pelvis and in the ovaries

• Its causes, pathogenesis, and natural course are poorly understood

• It is associated with an increased risk of coronary heart disease

Demographics

• Overall prevalence in the United States is 6–10%

Clinical Findings

Symptoms and Signs

• Dysmenorrhea, chronic pelvic pain, and dyspareunia, are among the well-recognized manifestations

• A significant number of women with endometriosis, however, remain asymptomatic

• Pelvic examination can disclose

  • Tender nodules in the cul-de-sac or rectovaginal septum

  • Uterine retroversion with decreased uterine mobility

  • Uterine tenderness

  • Adnexal mass or tenderness

Differential Diagnosis

• Pelvic inflammatory disease (PID)

• Ovarian neoplasms

• Uterine myomas

• Bowel neoplasm

Diagnosis

Imaging Studies

• Imaging is useful mainly in the presence of a pelvic or adnexal mass

• Transvaginal ultrasonography is the imaging modality of choice to detect the presence of deeply penetrating endometriosis of the rectum or rectovaginal septum

• MRI should be reserved for equivocal cases of rectovaginal or bladder endometriosis

Diagnostic Procedures

• Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery

Treatment

Medications

• Nonsteroidal anti-inflammatory drugs may be helpful

• Progestins, specifically oral norethindrone acetate and subcutaneous depot medroxyprogesterone acetate (DMPA), have been approved by the US Food and Drug Administration (FDA) for treatment of endometriosis-associated pain

• Intrauterine progestin, using the hormonal IUD, has also been shown to be effective in reducing endometriosis-associated pelvic pain, and may be considered before surgery

• Low-dose oral contraceptives can be given cyclically or continuously; prolonged suppression of ovulation will often inhibit further stimulation of residual endometriosis, especially if taken after one of the therapies mentioned here

• Any of the combination oral contraceptives, the contraceptive patch, or the vaginal ring

  • May be used continuously for 6–12 months

  • Breakthrough bleeding can be treated with conjugated estrogens, 1.25 mg orally daily for 1 week, or estradiol, 2 mg orally daily for 1 week

• The optimum duration of therapy is not known

• Gonadotropin-releasing hormone (GnRH) analogs

  • Nafarelin nasal spray, 0.2–0.4 mg twice daily, or long-acting injectable leuprolide acetate, 3.75 mg monthly intramuscularly, used for 6 months, suppress ovulation

  • Side effects consisting of vasomotor symptoms and bone demineralization may be relieved by "add-back" therapy with conjugated equine estrogen, 0.625 mg or norethindrone, 5 mg daily orally

• Unlike GnRH analogs, GnRH antagonists are effective immediately, rather than requiring 7–14 days for GnRH ...