Updated: 8/15/2019

Endometriosis

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Snapshot
  • A 29-year-old nulligravida presents with severe pain with menses and an inability to conceive after 24 months of unprotected intercourse. She reports feeling pain with defecation and intercourse. On pelvic exam, her uterus is found to be retroverted and there is nodularity of the uterosacral ligament on retrovaginal examination.
Introduction
  • Clinical definition
    • a nonmalignant condition where the endometrial glands and stroma are located outside of the uterus
  • Epidemiology
    • incidence
      • 7-10% of women in the US
    • demographics
      • only in female
      • most commonly in those 25-29 years of age
    • location
      • ovaries (most common)
      • uterosacral ligaments
      • retrouterine pouch (pouch of Douglas)
      • peritoneum
    • risk factors
      • family history
      • early menarche
      • nulliparity
  • Pathophysiology
    • pathobiology
      • ectopic endometrial tissue leads to an estrogen-stimulated inflammatory response
  • Associated conditions
    • chronic pelvic pain
    • endometrioma ("chocolate cyst")
      • endometriosis affecting the ovary
    • subfertility
  • Prognosis
    • natural history of disease
      • endometriosis may self-stabilize without treatment; however,
        • this may be a progressive, relapsing, or chronic condition
Presentation
  • Symptoms
    • dysmenorrhea
    • dyspareunia (painful intercourse)
    • dyschezia (painful defecation)
    • infertility
    • chronic pelvic pain
  • Physical exam
    • nodular thickening of uterosacral ligament
    • a fixed retroverted uterus
    • tender, fixed adnexal masses
Imaging
  • Ultrasonography
    • indications
      • first-line imaging modality to assess for endometriosis
Studies
  • Laparoscopic visualization with histologic confirmation
    • provides definitive diagnosis of endometriosis 
    • classically may see "powder burn" appearance
  • Histology
    • endometrial glandular tissue
Differential
  • Adenomyosis
  • Endometritis
  • Ovarian torsion
Treatment
  • Observation 
    • indicated for patients with asymptomatic endometriosis that is discovered incidentally
  • Medical
    • combined hormonal or progestin-only contraceptives
      • indications
        • considered first-line for pain due to endometriosis
    • gonadotropin-releasing hormone (GnRH) agonist
      • indications
        • second-line treatment for endometriosis
      • mechanism
        • inhibits gonadotropin secretion which
          • decreases FSH and LH levels leading to a suppression of ovarian function
    • levonorgestrel-releasing intrauterine device (IUD)
      • indications
        • another second-line treatment for endometriosis
    • danazol
      • indications
        • not commonly used due to side-effects
      • mechanism
        • suppreses FSH and LH pituitary secretion
  • Operative
    • laparoscopic ablation 
      • indications
        • surgery is the only definitive treatment and diagnostic modality
    • total abdominal hysterectomy with lysis of adhesions
      • indications
        • in patients who have completed childbearing with severe and recurrent disease
Complications
  • Complications
    • infertility
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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