Endometriosis is where functioning endometrial tissue is implanted in the pelvis outside the uterine cavity. Most commonly peritoneal but can show in large intestines, ureters, bladder, vagina, cervix, surgical scars. These tissue implants contain estrogen and progesterone receptors which allows them to grow, differentiate, and bleed in response to hormone changes during menstrual cycles. No matter the location of the implants, they cause localized inflammation that has the possibility of initiating sterile inflammation. Symptoms depend on the location of the implants and severity of symptoms is not related to the stage of it. There are a few working hypotheses as to how this happens but there is no definitive answer.
Typical Signs & Symptoms
Dysmenorrhea (painful menses)
Dyspareunia (pain during intercourse
Possible retroverted & fixed uterus
Signs & Symptoms Based On Location
Large intestine: pain during defecation, abdominal bloating, diarrhea or constipation, & rectal bleeding during menses
Bladder: dysuria, hematuria, pubic pain during urination, urinary frequency, urge incontinence
Ovaries: endometrioma (cystis) that can rupture and leak
Adnexal structures: pelvic mass or pain
Endometriosis is suspected with typical symptoms but confirmed with laparoscopy, laparotomy, vaginal examination, sigmoidoscopy, or cystoscopy. A biopsy is not required but may help, and ultrasonography may be useful after diagnosis. Did you know that endometrial tissue has a unique MR signal and MRI are becoming more useful, but not consistently.
Something important to keep in mind, is endometriosis is frequently misdiagnosed as pelvic inflammatory disease, UTI, or IBS.
NSAIDs (nonsteroidal) for discomfort
Drugs to suppress ovarian function aka
Gonadotropin-releasing hormone (GnRH) agonist and antagonists: suppresses estrogen by the ovaries
Danazol: inhibits ovulation
Ablation is good for more superficial implants & when restoring pelvic anatomy and preserving fertility is needed
Excision is for deep, extensive implants
Hysterectomy with or without removal of ovaries is usually recommended once childbearing years have passed or if the women doesn't have a desire for kids
Endometrial Staging: based on number, location, and depth of implants along with endometriomas & filmy adhesions. Stage 3 and 4 involve the ovaries, endometriomas, and filmy adhesions. Stage 4 involves possible adhesion of rectum to back of uterus
Stage 1 minimal
Stage 2 mild
Stage 3 moderate
Stage 4 severe
Endometriosis Fertility index (EFI): this helps to determine endometriosis associated infertility
Number of years infertile
History or absence of prior pregnancies
Least function score for both fallopian tubes, fimbria, and ovaries
American Society for Reproductive Medicine endometriosis scores
Who Is At A Higher Risk?
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