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endometriosis
Pathology:
- ectopic implants of endometrial tissue
- generally in pelvis
- may be anywhere
- cyclic bleeding from ectopic sites [3]
- hemoptysis if ectopic endometrial tissue in lung
- catamenial headache if ectopic endometrial tissue in CNS
- rectal bleeding during menses if ectopic endometrial tissue in rectum
Genetics:
- genetic variation in NRIP1 may act as predisposing factor for endometriosis
History: pelvic infections
Physical examination:
- may be normal
- abdominal masses & abdominal tenderness may be noted
- abnormalities of cervix, uterus, & adnexa on pelvic examination
- abnormalities of uterosacral ligaments on pelvic examination
Clinical manifestations:
1) chronic lower abdominal pain, chronic pelvic pain unrelated to menstrual cycle
- pain may be exacerbated by menses [10]
2) backache aggravated by menstruation
3) menorrhagia
4) dysmenorrhea
5) dyspareunia
6) in severe cases may have lower GI or urinary symptoms
7) primary or secondary infertility
8) palpable tender mass in pelvis or non-palpable tenderness [10]
9) nodular thickening of uterosacral ligament
10) fixed uterus
11) enlarged ovary
* endometriosis does not cause fever or vaginal discharge [3]
Laboratory:
- urine pregnancy test
Special laboratory:
- transvaginal ultrasound
- laparoscopy* is gold standard for diagnosis
* empiric trial of medical management before laparoscopy [10]
Complications:
- increased risk of inflammatory bowel disease (RR=1.5-1.6) [4]
- increased risk of myocardial infarction (RR=1.52) [8]
- ovarian subtype of endometriosis (endometrioma) associated with increased risk of ovarian cancer; absolute risk is low (0.02%/year) [9]
- catamenial hemopneumothorax is the most common complication of thoracic endometriosis
Management:
1) initial management if not contemplating pregnancy
a) analgesia, NSAIDs
b) oral contraceptive
2) failure of initial medical therapy
a) GnRH agonists: nafarelin, buserelin
b) progestins
c) danazol (last resort)
d) aromatase inhibitors
3) surgery
a) indications
1] failure of medical therapy
2] acute, severe &/or incapacitating pain
3] invasion of other organs (GI or GU tracts)
b) surgical strategies
1] laparoscopy vs laparotomy
2] conservative surgery: preservation of as much of uterus & ovaries as possible
3] definitive surgery: hysterectomy with or without removal of the ovaries & fallopian tubes
Interactions
disease interactions
Related
goserelin (Zoladex)
General
sign/symptom
uterine disease
References
- DeGowin & DeGowin's Diagnostic Examination, 6th edition,
RL DeGowin (ed), McGraw Hill, NY 1994, pg 882
- UpToDate version 15.2
http://www.utdol.com
- Medical Knowledge Self Assessment Program (MKSAP) 14, 16.
American College of Physicians, Philadelphia 2006, 2012
- Medical Knowledge Self Assessment Program (MKSAP) 19
Board Basics. An Enhancement to MKSAP19.
American College of Physicians, Philadelphia 2022
- Jess T et al
Increased risk of inflammatory bowel disease in women
with endometriosis: a nationwide Danish cohort study
Gut 2011, Dec 19
PMID: 22184069
http://gut.bmj.com/content/early/2011/12/04/gutjnl-2011-301095.abstract
- Giudice LC.
Clinical practice. Endometriosis.
N Engl J Med 2010 Jun 25; 362:2389.
PMID: 20573927
- Wong AY et al.
Levonorgestrel-releasing intrauterine system (Mirena) and
Depot medroxyprogesterone acetate (Depoprovera) as
long-term maintenance therapy for patients with moderate
and severe endometriosis: a randomised controlled trial.
Aust N Z J Obstet Gynaecol 2010 Jul 14; 50:273.
PMID: 20618247
- Practice bulletin no. 114: management of endometriosis.
Obstet Gynecol 2010 Jun 23; 116:223.
PMID: 20567196
(corresponding NGC guideline withdrawn Nov 2015)
- Mu F, Rich-Edwards J, Rimm EB et al
Endometriosis and Risk of Coronary Heart Disease.
Circulation. March 29, 2016
http://circoutcomes.ahajournals.org/content/early/2016/03/29/CIRCOUTCOMES.115.002224.abstract
- Saavalainen L, Lassus H, But A et al.
Risk of gynecologic cancer according to the type of
endometriosis.
Obstet Gynecol 2018 Jun; 131:1095
PMID: 29742675
- NEJM Knowledge+