Endometriosis Minimal

(score 1 – 5)
adnexal implants (<1 – 3cm)
 Filmy adhesions
Definition Stage II  Lesions >3cm
Mild  Some lesions deeply infiltrating
Presence of endometrial glands and stroma outside
(score 6 – 15)
the endometrial cavity & uterine musculature Stage III  Larger lesions
Moderate  More infiltration
(score 16 – 40)  Partial cul-de-sac obliteration
 Affects ~10% of women  Dense adhesions involving adnexa
 Typically occurs in women of reproductive age Stage IV  Deep ovarian lesions
 Incidence peaks at 40yo. Severe (endometrioma)
(score >40)  Dense adnexal adhesions
Risk factors/aetiology  Cul-se-sac obliteration
 Reproductive age group
 Positive FHx Test Findings
 Nulliparity Trans-vaginal U/S  Ovarian endometrioma
 Caucasian women (1st line)  Deep pelvic endometriosis e.g.
 Low BMI uterosacral ligament
Signs & symptoms Hystero-  Useful for suspected mullerian
salpingography anomaly e.g. unicorunate
 Dysmenorrhoea (more in early stage disease, uterus or uterine didelphys
where prostaglandin production is ↑) (double uterus)
 Pelvic pain (due to fibrosis & distorted normal MRI  Hypo-intense
anatomy)  Irregular thickening/ass of
utero-sacral ligament
 Dyspareunia
 Replacement of fat tissue plane
 Sub-fertility (up to 40% of women who
between uterus &
present with unexplained infertility) rectum/sigmoid with tissue
 Uterosacral ligament nodularity  “guitar mass
string” texture + tenderness Diagnostic lap +  Confirms endometrial
 Pelvic mass  “chocolate cyst” of ovarian histology glands/stroma outside uterine
endometrioma (gold standard) cavity
 Uterine tenderness Management
 Fixed, retroverted uterus  “frozen pelvis”
1. Stage I – II disease (mild)
 Bladder symptoms (dysuria, flank pain)
o COCP (atrophy of ectopic implants)
 Bowel symptoms (painful bowels, blood in
o NSAIDs (pain relief + COX-2 inhibition)
 Mefenamic acid  acts in
Criteria uterus
 Tranexamic acid  for
Score is based on: menorrhagia
 Appearance, size and depth of peritoneal and o GnRH agonists (leuprorelin +
ovarian implants oestrogen + medroxyprogesterone) 
 Presence, extent and type of lesions (red, red- suppresses oestrogen
pink and clear, white, peritoneal defects and o +/- surgical management
black) 2. Stage III – IV disease (severe)
 Presence, extent and type of pelvic adhesions o Radical excision of affected areas
(ovaries and tubes) and degree of cul-de-sac o Post-surgical HRT (GnRH agonist) 
obliteration androgen

Gold standard: hysterectomy + bilateral salpingo-
oophorectomy with excision of visible peritoneal
Staging Features
Stage I  Small, superficial peritoneal or