Endometriosis

By Amenah Shahin, 190021

Introduction
• It is a common, benign, and chronic disease in women of reproductive
age that is characterized by the presence of endometrial tissue outside
the uterus.
• The etiology is not fully established, but retrograde menstruation is
one of several factors involved.
• Symptoms commonly include dysmenorrhea, dyspareunia, chronic
pelvic pain, and infertility.
• Treatment is based on removal of endometrial tissue.
• It tends to recur, but symptoms and spread improve after menopause
and pregnancy.
Epidemiology
• Age of onset: 20-40 years
• Incidence: 2-10% of all women
• More common in white and Asian women than black and Hispanic
women.
Risk Factors
• Family history of endometriosis (7-10x increased risk if first degree relative)
• Nulliparity
• Early menarche Increased endogenous estrogen exposure
• Late menopause
• Short menstrual cycle
• Menorrhagia
• Low birth weight
• Obesity
• Genetics factor
Etiology—5 theories
1. Retrograde menstruation—most
accepted
2. Coelomic metaplasia (pluripotent cells)
3. Immune system dysfunction
4. Hematologic dissemination, lymphogenic
spread of endometrial cells
5. Extrauterine stem cell theory
Pathophysiology
• Endometrial tissue outside the uterus, commonly in:
• Pelvic organs
• Ovaries—most common site
• Cul-de-sac; Pouch of Douglas—2nd most common
• Fallopian tubes
• Broad ligaments, uterosacral
• Rectosigmoid colon
• Bladder
• Cervix
• Peritoneum
• Extrapelvic organs
• Lungs, brain, skin, nasal mucosa, umbilicus, diaphragm
• Most importantly, these endometrial cells are functional, with estrogen
receptors, and are responsive to hormones in the same way endometrium
does under influence of estrogen (cause of cyclical pain).
• However these cells are slightly different in that they have high levels of
aromatase enzyme and thus produce their own estrogen, and secrete pro-
inflammatory factors that lead to scarring and inflammation which leads to
adhesions (the cause of constant pain)
Complications
• Anemia
• Increased risk of ectopic pregnancy
(endometriosis in uterotubal junction inhibits
implantation of the zygote)
• Adhesions which lead to strictures and
entrapment of organs
• In intestines leading to constipation or diarrhea,
intestinal obstruction, ileus, intussusception
• In ureter leading to urine retention
• Associated with an elevated risk of ovarian
cancer, but not endometrial
Clinical features
Depending on where the cells are, the symptoms
appear, however there are general features
regardless of the place of endometrioma.
One fourth of affected women are asymptomatic
• Chronic pelvic pain, worsening before onset of
menses, cyclical.
• Dysmenorrhea
• Dyspareunia
• Infertility in 30% of women suffering from
endometriosis
Location of endometrial lesion Features
Uterosacral tenderness
Nodularity
Uterus Adnexa enlarged
Infertility; damage to uterus leads to difficult implantation of gamete
Lateral pelvic pain
Back pain
Ovaries Fixed, retroverted uterus
“Chocolate cyst”
Dysuria
Cyclic hematuria
Urinary tract Suprapubic tenderness
Recurrent UTIs
Incontinence
Dyschezia
Diarrhea
Intestines Constipation
Abdominal pain
Chest pain
Hemoptysis
Thorax Catamenial pneumo/hemothorax
Pulmonary nodules
Diagnosis
• History
• Physical exam
• Pelvic tenderness
• Fixed, retroverted uterus by cul-de-sac adhesions
• Uterosacral nodularities
• Rectovaginal tenderness
• Adnexal masses
• Transvaginal ultrasound
• Chocolate cysts in ovary
• Nodules in bladder or rectovaginal septum
• Uterus not enlarged
• Laprascopy (definitive, gold standard)
 Treatment
• Asymptomatic patient: expectant management
• Symptomatic patient: treatment is to manage pain, limit progression
of implants and address subfertility
Pharmacological options
• If mild-moderate pelvic pain without complications:
• NSAIDs with hormonal combined contraceptives (inhibits endometrium growth and ovarian
suppression), NSAIDS alone if desire to be pregnant. PSEUDOPREGNANCY (oral
contraceptives, DMPA, MPA)
• Danazol (steroid, inhibits mid-cycle surges of FSH and LH) PSEUDOMENOPAUSE
• Severe symptoms
• GnRH analogue (buserelin, goserelin, leuprolide) PSEUDOMENOPAUSE
• Estrogen-Progestin OCPs PSEUDOPREGNANCY
Pseudopregnancy: preventing progesterone withdrawal bleeding
Pseudomenopause: inhibition of HPO axis atrophic changes
NOTE:
• Patients on leuprolide therapy for more than 3-6 months complain of
menopausal symptoms; hot flashes, sweats, vaginal dryness,
personality changes. Following six months, birth-control medication
can be used; DMPA which suppresses FSH and LH but has no
vasomotor symptoms.
Surgical options
• First-line: laparoscopic excision and ablation of implants, lysis of
adhesions—CONSERVATIVE MANAGEMENT
• To confirm diagnosis and exclude malignancy
• For people who haven’t responded to pharmacotherapy
• For complications such as infertility and bowel/bladder obstruction and rupture of
endometrioma.
• Second-line: Hysterectomy with/out bilateral salpingo-oophorectomy with
estrogen replacement therapy—AGGRESSIVE MANAGEMENT
• For treatment-resistant symptoms (pain is debilitating)
• Completed childbearing
References
• Kaplan USMLE Step 2 CK Lecture Notes, 2021
• Obstetrics by Ten Teachers, 20th edition
• Online resources
Thank you!