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Endometriosis

Last updated: November 10, 2020

Summary

Endometriosis is a common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue outside the uterus. The etiology of endometriosis is not yet fully established; however, retrograde menstruation is one of several factors involved. Symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Treatment is based on the individual disease manifestation and may either involve the administration of pain relievers and hormonal therapy or surgical removal of endometriotic tissue. Endometriosis tends to recur, but symptoms and disease spread improve after pregnancy in many cases, as well as in menopause.

Epidemiology

  • Age of onset: 20–40 years
  • Incidence: 2–10% of all women
  • Ethnicity: In the US, endometriosis is more common in white and Asian women than in black and Hispanic women.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • The etiology of endometriosis is not yet fully understood; however, retrograde menstruation seems to play a major role in the pathogenesis of endometriosis.
  • Other contributing factors include:

Pathophysiology

  • In endometriosis, endometrial tissue occurs outside of the uterus.
  • Common locations of endometriotic implants include:
  • Regardless of where the endometrial tissue is located, it reacts to the hormone cycle; in much the same way as the endometrium and proliferates under the influence of estrogen.
  • Endometriotic implants result in:
    • ↑ Production of inflammatory and pain mediators
    • Nerve dysfunction
    • Altered anatomy (e.g., pelvic adhesions) → infertility

References: [1]

Clinical features

Endometriosis may also be asymptomatic in many women and appear as an incidental finding during surgery performed for another reason.

References: [2]

Diagnostics

Normally the severity of the findings does not correlate with the severity of symptoms.

References:[2][3]

Pathology

  • Endometrial implants present macroscopically as yellow-brown (sometimes reddish-blue) blebs, islands, or pinpoint spots.
  • Gunshot lesions or powder-burn lesions; : black, yellow-brown, or bluish nodules or cystic structures seen on the serosal surfaces of the ovaries and peritoneum
  • Ovarian endometriomas or chocolate cysts; : cyst-like structures that contain blood, fluid, and menstrual debris
  • Fallopian tubes
    • Salpingitis isthmica nodosa: nodular tube changes
      • Result
  • Histologic findings

Differential diagnoses

For more information, see “Differential diagnosis of dysmenorrhea and menorrhagia.

Adenomyosis

References:[4][5]

The differential diagnoses listed here are not exhaustive.

Treatment

References:[3][5][6][7]

Complications

We list the most important complications. The selection is not exhaustive.

References

  1. Parasar P, Ozcan P, Terry KL. Endometriosis: Epidemiology, diagnosis and clinical management. Curr Obstet Gynecol Rep. 2017; 6 (1): p.34-41. doi: 10.1007/s13669-017-0187-1 . | Open in Read by QxMD
  2. Laufer MR. Endometriosis in adolescents: Diagnosis and treatment. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/endometriosis-in-adolescents-diagnosis-and-treatment.Last updated: April 12, 2016. Accessed: February 17, 2017.
  3. Stewart E. Uterine adenomyosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-adenomyosis?source=search_result&search=adenomyosis&selectedTitle=1~51#H6.Last updated: February 9, 2017. Accessed: February 17, 2017.
  4. Dutta DC, Konar H. DC Dutta's Textbook of Gynecology. Jaypee Brothers Medical Publishers ; 2013
  5. Schenken RS. Endometriosis: Treatment of pelvic pain. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/endometriosis-treatment-of-pelvic-pain?source=machineLearning&search=endometriosis&selectedTitle=1~150§ionRank=1&anchor=H3#H3.Last updated: February 2, 2017. Accessed: February 17, 2017.
  6. Lebovic DI. Endometriosis: Surgical Management of Pelvic Pain. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/endometriosis-surgical-management-of-pelvic-pain.Last updated: August 24, 2017. Accessed: March 2, 2018.
  7. Saraswat L, Ayansina D, Cooper K, et al. Pregnancy outcomes in women with endometriosis: a national record linkage study. BJOG. 2016; 124 (3): p.444-452. doi: 10.1111/1471-0528.13920 . | Open in Read by QxMD
  8. Berlanda N, Vercellini P, Fedele L. Endometriosis: Clinical Manifestations and Diagnosis of Rectovaginal or Bowel Disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/endometriosis-clinical-manifestations-and-diagnosis-of-rectovaginal-or-bowel-disease.Last updated: June 18, 2017. Accessed: December 11, 2017.
  9. Wei J-J, William J, Bulun S. Endometriosis and Ovarian Cancer. International Journal of Gynecological Pathology. 2011; 30 (6): p.553-568. doi: 10.1097/pgp.0b013e31821f4b85 . | Open in Read by QxMD
  10. Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. Elsevier Saunders ; 2015
  11. Endometriosis. http://www.mayoclinic.org/diseases-conditions/endometriosis/home/ovc-20236421. Updated: August 20, 2016. Accessed: February 17, 2017.