What is Endometriosis?


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

  • Adnexal masses

  • Infertility

  • Interstitial cystitis

  • Breakthrough bleeding

  • 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

Diagnosis

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.

Treatment

  • NSAIDs (nonsteroidal) for discomfort

  • Drugs to suppress ovarian function aka

  • oral contraceptives

  • Progestins

  • 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

  • Age

  • 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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