Endometriosis Overview and Symptoms

Definition

• Endometriosis is a condition where endometrial tissue (typically found in the lining of the uterus) grows outside of the uterus.
• This condition is benign, meaning it is not cancerous.

Occurrence

• Endometriosis affects approximately one-third or more women experiencing chronic pelvic pain.
• Most commonly diagnosed in women in their 30s, who have not given birth, and are infertile.
• However, it can affect women throughout their reproductive years.

Theories of Pathogenesis

• Retrograde menstruation is a leading theory for endometriosis.
• During menstruation, endometrial fragments are transported through the fallopian tubes and implant at various locations within the abdomen.

Sites of Occurrence

• Ovaries
• Cul-de-sac
• Uterosacral ligaments
• Broad ligament
• Fallopian tubes
• Round ligaments
• Vagina
• Rectosigmoid and bowel, appendix
• Urinary bladder and ureters

Symptoms

• Dysmenorrhea (painful menstruation)
• Dyspareunia (painful intercourse)
• Dyschezia (pain with bowel movements)
• Cyclic and non-cyclic pelvic pain
• Infertility
• Secondary dysmenorrhea
• Premenstrual and postmenstrual spotting (approximately 20% of cases)

Physical Exam

• No specific sign can definitively confirm endometriosis.
• Common findings include:
  • Recto-vaginal exam findings
  • Cul-de-sac nodularity and tenderness
  • Uterosacral nodularity
  • Tender, fixed adnexal mass
  • Uterus fixed and retroverted

Diagnosis

• Ruling out other causes is crucial.
• Ultrasound: An adnexal mass with complex echogenicity and internal echoes consistent with blood can be observed.
• Definitive Diagnosis: Visual examination with laparotomy or laparoscopy, and histological confirmation of endometrial tissue.
• Other tests, including Ca125, are not reliable indicators of endometriosis.

Pathology

• "Chocolate cysts" in the ovaries are a common characteristic of endometriosis.
• These cysts are filled with old endometrial shedding and blood, giving them a thick, tarry consistency.
• Ruptured cysts can cause chemical peritonitis.
• Adhesions are a common consequence of endometriosis.

Staging

• A staging system exists for endometriosis, but there is no clear correlation between the stage and the severity or frequency of pain symptoms.

Management Considerations

• Severity of Symptoms
• Extent of the disease
• Desire for future fertility
• Age of the patient
• Threat to the Gastrointestinal or Urinary tract

Treatment Options

• Excision or ablation surgery
• Pelvic physical therapy
• Medications for pain, birth control, and GnRH agonists
• Treatments for co-occurring conditions
• Self-care

Medical Management

• First-line treatment (minimum of three to six months):
  • Oral contraceptive pills (OCP’s), cyclic or continuous
  • Progestins
  • Aromatase inhibitors
• Referral for laparoscopy for diagnosis and treatment if these fail.
• Second-line medical treatments (usually after laparoscopy):
  • Mirena IUD (levonorgestrel)
  • GnRH agonists (Lupron)
• GnRH agonists should not be administered without prior diagnostic laparoscopy.
  • Pain relief alone does not confirm an endometriosis diagnosis.

Surgical Management

• Fertility-preserving:
  • Laparoscopy (or rarely, laparotomy) with ablation or excision of endometrial implants and adhesions.
  • Endometriomas larger than 3 centimeters in diameter should be surgically removed.
• Most definitive:
  • Hysterectomy (often laparoscopic) with ablation or excision of all endometrial implants and adhesions.
• Removal of ovaries was previously a traditional option, but recent studies suggest that preserving ovaries is reasonable in many cases.
• Recurrence is always a risk.

Related Disorder: Adenomyosis

• Ectopic endometrial tissue within the myometrium.
• Typically affects parous women between 35 and 50 years old.
• Symptoms:
  • Often asymptomatic
  • Secondary dysmenorrhea, abdominal pressure, bloating
  • Menorrhagia
  • Dyspareunia, sometimes chronic pelvic pain
• Examination findings:
  • Diffusely enlarged, globular, tender uterus
• Diagnosis:
  • Strong clinical suspicion based on history findings and exam findings
  • Characteristic findings on ultrasound and MRI
  • Definitive diagnosis confirmed through pathology report.

Bottom Line Concepts

• Endometriosis is most prevalent among women in their reproductive years who are subfertile.
• The exact cause of endometriosis remains uncertain and is likely attributed to a combination of factors.
• Dysmenorrhea, dyspareunia, and dyschezia are the classic symptoms associated with endometriosis.
• The stage of endometriosis does not reliably correlate with the frequency or severity of pain.
• Treatment approaches vary and should consider the severity of symptoms, disease extent, future fertility aspirations, and patient age.
• Endometriosis can reoccur throughout a woman's life.
• Minimizing menstrual flow and suppressing ovarian cycling can reduce the risk and symptoms of endometriosis.

Endometriosis Definition

• Endometrial glands and stroma are found outside the uterine cavity and walls.
• This condition is benign.

Endometriosis Occurrence

• Affects more than one third of women with chronic pelvic pain.
• Most common in women in their 30s.
• Often presents in nulliparous women (women who have never given birth).
• Commonly associated with infertility.
• Can present throughout the reproductive years.

Pathogenesis of Endometriosis

• Endometrial fragments transported through fallopian tubes at time of menstruation and implant at intraabdominal sites.

Endometriosis Sites of Occurrence

• Ovary (most common)
• Cul-de-sac
• Uterosacral ligaments
• Broad ligament
• Fallopian tubes
• Round ligaments
• Vagina
• Rectosigmoid and bowel, appendix
• Urinary bladder and ureters

Endometriosis Symptoms

• Classic Triad: dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), and dyschezia (painful defecation).
• Pain (cyclic and non-cyclic).
• Infertility.
• Secondary dysmenorrhea.
• Premenstrual and postmenstrual spotting.

Physical Exam

• No pathognomonic finding (no “telltale sign”).
• Potential findings:
  • Recto-vaginal exam findings.
  • Cul-de-sac nodularity and tenderness.
  • Uterosacral nodularity.
  • Tender, fixed adnexal mass.
  • Uterus fixed and retroverted.

Diagnosis

• Rule out other causes.
• Ultrasound – adnexal mass of complex echogenicity, internal echoes consistent with blood.
• Definitive diagnosis:
  • Direct visualization (via laparotomy or laparoscopy).
  • Histologic and gross findings consistent with endometrial tissue.
  • Other tests.
  • Ca125 - not specific nor sensitive; not a reliable indicator of endometriosis.

Pathology of Endometriosis

• “Chocolate cysts” of the Ovary:
  • Endometrial cysts filled with old endometrial sheddings and blood.
  • Typically very tarry and sticky.
  • Can cause chemical peritonitis if ruptured .
  • These cysts are characteristic of endometriosis.
• Adhesions.

Staging

• A system of staging exists so that caregivers can communicate with each other re: locations of disease.
• There is no clear relationship between stage and frequency and severity of pain symptoms.

Management

• Key considerations:
  • Severity of the symptoms.
  • Extent of the disease.
  • Desire for future fertility.
  • Age of the patient.
  • Threat to GI or urinary tract.

Endometriosis Treatment Options

• Excision or ablation surgery.
• Pelvic physical therapy.
• Medication for pain, birth control and GnRH agonists.
• Treatments for co-occurring conditions.
• Self-care.

Medical Management

• 1st line treatment (adequate trial of 3-6 months).
  • OCP’s , cyclic or continuous.
  • Progestins (i.e.MPA or DMPA).
  • Aromatase Inhibitors.
• If these are failing, strongly consider laparoscopy to both diagnose and treat the disease.
• 2nd line medical treatments (usually tried after diagnosis confirmed by laparoscopy).
  • Mirena IUD (levonorgestrel).
  • GnRH agonists (Lupron).
    • Should not be done without laparoscopy first.
    • Relief of pain does not make the diagnosis of endometriosis.
• GnRH Agonists.
  • Monthly or q3 months x 6 months; no more than 2 courses unless patient is on add back therapy.

Surgical Management

• Fertility preserving:
  • Laparoscopy (or rarely, laparotomy) with ablation or excision of endometrial implants and adhesions.
  • Endometriomas >3 cm in diameter should be removed surgically.
• Most definitive:
  • Hysterectomy (most often laparoscopic) with ablation or excision of all endometrial implants and adhesions.
  • Removal of ovaries has been traditional, but newer studies suggest retention of ovaries is reasonable in many cases.
• Risk of recurrence:
  • Always a risk of recurrence!

Adenomyosis

• This is a related disorder characterized by the presence of ectopic endometrial tissue within the myometrium.
• Who gets this?
  • Usually parous women (women who have given birth).
  • Predominantly between the ages of 35-50 years old.
• Symptoms:
  • Often asymptomatic.
  • Secondary dysmenorrhea.
  • Abdominal pressure.
  • Bloating.
  • Menorrhagia.
  • Dysparenuia, sometimes chronic pelvic pain.
• Signs on examination:
  • Diffusely enlarged, globular, tender uterus.
• Diagnosis:
  • High index of suspicion based on clinical history and exam findings.
  • Characteristic findings on ultrasound and MRI.
  • Definitive dx = Pathology report.

Bottom Line Concepts

• The typical patient with endometriosis is in her reproductive years and sub-fertile.
• Pathogenesis of endometriosis is not completely understood and is probably a combination of factors.
• The characteristic triad of symptoms associated with endometriosis is dysmenorrhea, dyspareunia, and dyschezia.
• Stage of endometriosis is not clearly associated with the frequency and severity of pain symptoms.
• Appropriate treatment varies widely and should take into consideration severity of symptoms, extent of disease, and desire for future fertility.
• There is a risk of recurrence of endometriosis throughout a woman’s life.
• Minimizing menstrual flow and suppressing ovarian cycling can reduce the risk for/symptoms of endometriosis.