Gynecology Book

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Endometriosis

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  1. Epidemiology
    1. Age at diagnosis: 20-40 years
    2. Prevalence: 10-15% of women
      1. Prevalence in women with Pelvic Pain: 82%
      2. Prevalence in women with Infertility: 21%
      3. Eskenazi (1997) Obstet Gynecol Clin North Am 24:235
  2. Pathophysiology: Ectopic Endometrial Tissue implant Sites
    1. Ovary (50%)
    2. Uterosacral ligaments
    3. Rectovaginal septum
    4. Sigmoid colon
    5. Serosal surface of
      1. Uterus or fallopian Tubes
      2. Cervix, Vagina or vulva
      3. Bladder
    6. Distant intrapelvic or low Abdominal Sites
      1. Appendix or Ileum
      2. Abdominal scars
      3. Umbilicus
      4. Ureter
    7. Distant extrapelvic sites (rare)
      1. Diaphragm, Pleura, or Lungs
      2. Spleen
      3. Gallbladder
      4. Kidney
  3. Pathophysiology: Theories of etiology
    1. Implantation during menstruation (Sampson)
      1. Endometrial cells spread via tube to peritoneum
      2. Referred to as retrograde flow
    2. Vascular and lymphatic spread (Halban)
      1. Associated with abdominal surgery
      2. Would explain distant spread to organs such as lung
    3. Metaplasia (Meyer)
      1. Coelomic epithelium differentiates into endometrium
    4. Decreased Cellular immunity (Dmowski)
  4. Risk Factors
    1. Mother or sister with endometriosis (Odds Ratio 7.2)
    2. Menstrual flow 6 or more days (Odds Ratio 2.5)
    3. Menstrual Cycle <28 days (Odds Ratio 2.1)
    4. References
      1. Mounsey (2006) Am Fam Physician 74:594
  5. Symptoms
    1. Asymptomatic in 25-30% of women with endometriosis
    2. Chronic Pelvic Pain (70%)
    3. Dysmenorrhea (71%)
      1. Cyclic
      2. Progressively increasing in severity
      3. Affects bilateral lower abdomen
      4. Associated with sense of rectal pressure
      5. Refractory to anti-prostaglandins
    4. Dyspareunia (44%)
    5. Infertility (15-20%)
    6. Painful Defecation (dyschezia)
    7. Premenstrual spotting
    8. Heavy Menstrual Bleeding
    9. Suprapubic Pain
    10. Dysuria
    11. Hematuria
  6. Signs: Pelvic exam
    1. Tender, nodular uterosacral ligaments
    2. Fixed uterine retroversion
  7. Diagnosis
    1. Laparoscopy
      1. Brown or blue-black Nodules
      2. Powder-burn spots
        1. Multiple, tiny, puckered hemorrhagic foci
    2. Histology (confirms visual diagnosis)
      1. Hemosiderin-laden Macrophages
      2. Endometrial tissue (epithelium, glands, stroma)
    3. Tests not recommended for diagnosis
      1. CA 125
      2. CA 19-9
      3. MRI abdomen
  8. Imaging
    1. Trasvaginal ultrasound
      1. Identifies retroperitoneal and uterosacral lesions
      2. Misses endometriomas and peritoneal lesions
  9. Differential Diagnosis
    1. See Dysmenorrhea
    2. See Dyspareunia
    3. See Infertility
    4. See Pelvic Pain
  10. Management: First Line
    1. Laparoscopy recommended initially if fertility desired
    2. Oral Contraceptives
      1. Use for at least 3-4 months
      2. Desogestrel OCPs (moderate Progestin, low Estrogen)
        1. Desogen (monophasic, 30 mcg Ethinyl Estradiol)
        2. Ortho-Cept (monophasic, 30 mcg Ethinyl Estradiol)
        3. Mircette (monophasic with 20 mcg Ethinyl Estradiol)
        4. Cyclessa (triphasic with 25 mcg Ethinyl Estradiol)
    3. Progesterone
      1. Provera 20-30 mg qd for 2 months
      2. Depo Provera q3 months
        1. Higher Incidence of adverse effects
      3. Mirena IUD
    4. High Dose Progesterone (not recommended)
      1. Unclear efficacy and safety
      2. Recent study suggests no benefit over standard dose
      3. Protocol
        1. Start: Depo Provera 150 mg IM q2 weeks for 4 doses
        2. Next: Depo Provera 150 mg IM monthly for 4 months
        3. Last Provera 30-50 mg for 4-6 months
  11. Management: Second Line
    1. Gonadotropin-releasing Hormone Agonist (GnRH)
      1. Agents
        1. Leuprolide (Lupron)
          1. Dose: 3.75 mg injected every 4 weeks
        2. Goserelin (Zoladex)
          1. Implanted 3.6 mg SubQ for 6 months or
        3. Nafarelin (Synarel)
          1. Dose: 200 mcg intranasal bid x6 month
        4. Buserelin
        5. Decapeptyl
      2. Adverse effects (Hypoestrogenic)
        1. Consider add-back of low dose Estrogen
      3. Efficacy
        1. Up to 100% improvement for 6-12 months post-therapy
    2. Other hormonal agents
      1. Danazol (androgenic agent)
        1. Dose: 200-800 mg PO qd for 6 months
        2. Efficacy: Improvement in 55-93% of patients
        3. Adverse effects in up to 85% of patients
      2. Gestrinone (anti-Progestin agent)
        1. Dose: 2.5 mg PO bid for 6 months
      3. Norethindrone 2.5 mg PO and Premarin 0.625 mg PO qd
  12. Management: Surgical
    1. Laparoscopy for diagnosis and treatment
      1. Laser or electrocautery of implanted endometrium
    2. Pain Management (unclear efficacy)
      1. Presacral neurectomy (midline pain)
      2. Laparoscopic uterosacral nerve ablation (LUNA)
    3. Refractory cases
      1. Hysterectomy with oophorectomy and lesion ablation
        1. Endometriosis may still recur in up to 10% of cases
  13. Complications
    1. Infertility (50-60%)
    2. Minimal to no risk of malignancy
  14. Resources
    1. Endometriosis Association
      1. http://www.endometriosisassn.org
  15. References
    1. Mounsey (2006) Am Fam Physician 74:594
    2. Vercellini (2003) Fertil Steril 80:560
    3. Winkel (2003) Obstet Gynecol 102:397

Endometriosis, site unspecified (C0014175)

Definition (MSH)A condition in which functional endometrial tissue is present outside the UTERUS. It is often confined to the PELVIS involving the OVARY, the ligaments, cul-de-sac, and the uterovesical peritoneum.
Definition (CSP)condition in which tissue more or less perfectly resembling the uterine mucous membrane (the endometrium) and containing typical endometrial granular and stromal elements occurs aberrantly in various locations in the pelvic cavity.
Definition (NCI)(en-do-mee-tree-O-sis) A benign condition in which tissue that looks like endometrial tissue grows in abnormal places in the abdomen.
ConceptsDisease or Syndrome (T047)
ICD9617, 617.9
MSHD004715
EnglishEndometrioses, Endometriosis, Endometriosis -RETIRED-
Spanishendometriosis, endometriosis - RETIRADO -
Parent ConceptsFemale Genital Diseases (C0017411), Female Reproductive System Disorder (C0236100), Endometriosis, site unspecified (C0014175), Other female genital tract disorders (C0178291), Female Non-Neoplastic Reproductive System Disorder (C1333603), Proliferation (C0334094), Ambiguous concept (C1274012), Disorder characterized by pain (C1300028), Reason not stated concept (C1276325)
SourcesCCS, COSTAR, CSP, CST, DXP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, OMIM, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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