Updated: 11/29/2021

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.
  • SUmmary
    • Clinical definition
      • a nonmalignant condition where the endometrial glands and stroma are located outside of the uterus
    • 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
  • 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
  • ETIOLOGY
    • Pathophysiology
      • pathobiology
        • ectopic endometrial tissue leads to an estrogen-stimulated inflammatory response
  • 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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(M2.GN.15.137) A 26-year-old woman presents to her gynecologist with complaints of pain with her menses and during intercourse. She also complains of chest pain that occurs whenever she has her menstrual period. The patient has a past medical history of bipolar disorder and borderline personality disorder. Her current medications include lithium and haloperidol. Review of systems is notable only for pain when she has a bowel movement relieved by defecation. Her temperature is 98.2°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 98% on room air. Pelvic exam is notable for a tender adnexal mass. The patient's uterus is soft, boggy, and tender. Which of the following is the most appropriate method of confirming the diagnosis in this patient?

QID: 104777

Clinical diagnosis

1%

(1/96)

Endometrial biopsy

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(67/96)

Laparoscopy

8%

(8/96)

MRI

6%

(6/96)

Transvaginal ultrasound

12%

(12/96)

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Evidence (12)
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