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Endometriosis
Endometriosis is characterized by the presence of endometrial tissue on the ovaries, fallopian tubes or other abnormal sites, causing pain or infertility. Women are usually 25 to 29 years old at the time of diagnosis.
Approximately 24 percent of women who complain of pelvic pain are subsequently found to have endometriosis. The overall prevalence of endometriosis is estimated to be 5 to 10 percent.
Clinical evaluation
Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms.
Differential Diagnosis of Endometriosis
Generalized pelvic pain
Pelvic inflammatory disease
Endometritis
Pelvic adhesions
Neoplasms, benign or malignant
Ovarian torsion
Sexual or physical abuse
Nongynecologic causes
Dysmenorrhea
Primary
Secondary (adenomyosis, myomas, infection, cervical stenosis)
Dyspareunia
Musculoskeletal causes (pelvic relaxation, levator spasm).
Gastrointestinal tract (constipation, irritable bowel syndrome).
Urinary tract (urethral syndrome, interstitial cystitis).
Infection.
Pelvic vascular congestion.
Diminished lubrication or vaginal expansion because of insufficient arousal
Infertility
Male factor.
Tubal disease (infection).
Anovulation.
Cervical factors (mucus, sperm antibodies, stenosis).
Luteal phase deficiency
Infertility may be the presenting complaint for endometriosis. Infertile patients often have no painful symptoms.
Physical examination. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination should identify uterosacral, cul-de-sac or septal nodules. Most women with endometriosis have normal pelvic findings.
Treatment
Confirmatory laparoscopy is usually required before treatment is instituted. In women with few symptoms, an empiric trial of oral contraceptives or progestins may be warranted to assess pain relief.
Progestational agents. Progestins are similar to combination OCPs in their effects on FSH, LH and endometrial tissue. They may be associated with more bothersome adverse effects than OCPs. Progestins are effective in reducing the symptoms of endometriosis. Oral progestin regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg) . Depot medroxyprogesterone may be given intramuscularly every two weeks for two months at 100 mg per dose and then once a month for four months at 200 mg per dose.
Oral contraceptive pills (OCPs) suppress LH and FSH and prevent ovulation. Combination OCPs alleviate symptoms in about three quarters of patients. Oral contraceptives can be taken continuously (with no placebos) or cyclically, with a week of placebo pills between cycles. The OCPs can be discontinued after six months or continued indefinitely.
Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent.
Surgical treatment
Surgical treatment is the preferred approach to infertile patients with advanced endometriosis. Laparoscopic ablation of endometriosis lesions may result in a 13 percent increase in the probability of pregnancy.
Definitive surgery, which includes hysterectomy and oophorectomy, is reserved for women with intractable pain who no longer desire pregnancy.
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