Endometriosis is a benign, usually progressive, and sometimes recurrent disease

that involves locally and disseminates widely. Possible casual factors of

endometriosis include retrograde menstruation, coelomic metaplasia, vascular
metastasis, immunologic changes, iatrogenic dissemination, and a genetic
predisposition.
Endometriosis lesions produce estrogen locally and have increased secretion of
prostaglandins and inflammatory cytokines, which cause pain and contribute to
infertility. There is also a relative resistance to progesterone in endometriosis
lesions.
Grossly, endometriosis appears in many forms, including red, brown, black, white,
yellow, pink, or clear vesicles and lesions. Red, blood-filled lesions are in the most
active phase of endometriosis. Approximately 10% of teenagers who develop
endometriosis have associated congenital outflow obstruction.
The two primary short term goals in treating endometriosis are the relief of pain and
the promotion of fertility. The primary long term goal in the management of a
woman with endometriosis is attempting to prevent progression or recurrence of the
disease process. The recurrence rate following medical therapy is 5% to 15% in the
first year and increases to 40% to 50% in 5 years.
The side effects associated with GnRH agonist therapy are primarily those
associated with estrogen deprivation, similar to menopause. The three most
common symptoms are hot flushes, vaginal dryness, and insomnia. A decrease in
bone mineral content of trabecular bone has been demonstrated in the cortical
bone on the lumbar spine by quantitative computed tomography.
Many clinicians add back very low doses of estrogen, low doses of progestins, or
both in combination with chronic GnRH agonist therapy. The incidence of
endometriosis is 30% to 45% in women with infertility. There is probably some
benefit to abrading endometriosis lesions when seen at laparoscopy. In patients with
endometriosis, the success of IVF-ET may decrease by 20%.
Classic symptoms of endometriosis of the large bowel include cyclic pelvic cramping
and lower abdominal pain and rectal pain with defecation, especially during the
menstrual period. Endometriosis of the bladder is discovered most often in the
region of the trigone or the anterior wall of the bladder. Bladder endometriosis
produces midline, lower abdominal, and suprapubic pain, dysuria, and, occasionally,
cyclic hematuria.