Background

Endometriosis is 'functional endometrial tissue outside the uterus'. It acts in the same way as normal uterine tissue i.e. proliferates and sheds in accordance with woman’s menstrual cycle. As it involves bleeding into the pelvic cavity, blood is unable to leave → irritation and local inflammatory response → healing → fibrosis → adhesions

 

 Both the aetiology and pathophysiology are unknown, but theories include:

  • retrograde menstruation
  • de-differentiation of cells followed by transformation to endometrial cells
  • genetic
  • vascular or lymphatic spread.

 

    Symptoms

    Endometriosis symptoms

    The symptoms can be varied and partly depend on the site of endometriosis.  Consequently it is often difficult to diagnose the condition. Common sites of endometrial deposits are:

     

    • ovary (which may contain endometriomas/chocolate cysts)
    • bladder
    • rectovaginal septum
    • rectouterine pouch of Douglas
    • vesicouterine pouch
    • myometrium (then called adenomyosis)

     

    Cyclical pain is a key symptom.  It is often not eased by over-the-counter analgesia and results in a lot of time off work.  Endometriosis can be asymptomatic and an incidental finding, e.g. as part of subfertility investigations.  One third of women with endometriosis complain of subfertility, although how mild endometriosis affects fertility is unknown

     

    Symptom severity ≠ extent of endometriosis seen laparoscopically.

     

    Differential diagnoses are countless.  Irritable bowel syndrome and pelvic inflammatory disease also cause similar, non-specific symptoms.  

    Examination

    PV exam is often not useful.  Signs associated with, although not exclusive to, endometriosis are indicated in the diagram.

    Endometriosis signs

    Investigations

    Laparoscopy is the gold standard.  During the laparoscopy, biopsies can be taken from suspicious areas, although a negative histology report does not rule out endometriosis. Laparoscopy also allows for simultaneous treatment and patient's should be consented for this prospectively before the laparoscopy.

     

    Ultrasound is only useful for large endometriomas.

    Medical Treatment

    Only symptomatic treatments are available - there is no cure.  Medical treatment should be tailored to the individual and their current situation; age, symptoms, family plans etc.  

    The table is not exhaustive - only information relative to the use of these medications in endometriosis is included. More information can be found in other articles such as 'contraception'.  

    Surgical Treatment

    Open surgery should be avoided if possible as the associated adhesions can make endometriosis worse.  Women with mild-moderate disease are more likely to benefit from surgery than those with severe disease.  Surgery is not a guarantee that the woman will no longer experience pelvic pain, even if she has a hysterectomy and bilateral salpingoophrectomy (BSO).

     

    Surgical interventions that may be possible include:

     

    1.  Laparoscopic ablation of endometriosis.  Can be performed using diathermy or laser.

      2.  Laparoscopic excision of endometriotic lesions. 

        3.  Laparoscopic adhesiolysis may decrease pain associated with adhesions.

          4.  Laparoscopic drainage of endometriomas

          5.  Hysterectomy with retention of one or both ovaries - retains some natural oestrogen production and so HRT is usually not required.  20% need futher surgery.  

          6.  Hysterectomy and BSO - most definitive treatment. Fertility will be lost and menopause is induced so thorough counselling is essential. There remains the possibility that residual tissue may malignant change.  

             

            Options 1-4 all allow retention of fertility; 5 and 6 are not appropriate if the woman wishes to remain fertile. If the woman is trying to conceive, laparoscopic tubal flushing may be of benefit, as might intra-uterine insemination (IUI), or in-vitro fertilisation (IVF). 

            Psychological Aspects

            It is important to consider the psychological effects of this condition. Often women have been suffering with these symptoms for years before it is diagnosed.  Some may believe they have cancer. In addition to sometimes debilitating symptoms, women may have to cope with potential subfertility, and also the impact the disease has on her family and friends. It is a progressive disorder which worsens with time and for which there is no cure. Some women may benefit from counselling or referral to the chronic pain team.

            Trivia

            • Several cases of endometriosis have been reported in men
            • Famous people with endometriosis include Louise Redknapp, Anthea Turner, Annabel Croft and Susan Sarandon
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