Endometriosis 4-1-11

UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Endometriosis
 Describe the theories of pathogenesis of
 List the most common sites of endometriosis
 Describe the symptoms and physical exam findings in
a patient with endometriosis
 Describe the diagnosis and management of
 Benign condition in which endometrial glands
and stroma are present outside the uterine
cavity and walls
 Prevalence of endometriosis in general population
 Estimated 5-15% of women have some degree of
 Found in 1/3rd or more women with chronic pelvic
pain, depending on practice setting
 Typical patient is in her 30’s, nulliparous, and
infertile, but can present throughout the
reproductive years.
Theories of Pathogenesis
 Retrograde menstruation (Sampson’s Theory)
 Endometrial fragments transported through fallopian tubes at time
of menstruation and implant at intraabdominal sites
 Müllerian (Coelomic) metapalasia theory (Meyer’s Theory)
 Metaplastic transformation of pelvic peritoneum
 Lymphatic spread (Halban’s Theory)
 Substances released/shed from endometrium induce formation of
Theories of Pathogenesis
However, since retrograde menstruation is essentially
universal, host factors must impact the development of
“disease”, such as:
• variations in the ability to “clean up” menstrual
debris, probably reflecting immunologic events.
•Genetic differences in the tendency to develop painful
•Medical and psychological comorbidities
Sites of Occurrence
Ovary (most common)
Uterosacral ligaments
Broad ligament
Fallopian tubes
Round ligaments
Rectosigmoid and bowel, appendix
Urinary bladder and ureters
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology,
5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel, Chapter
25 (p299).
Classic Triad - dysmenorrhea, dyspareunia, dyschezia
Pain (cyclic and non-cyclic)
Secondary dysmenorrhea
Premenstrual and postmenstrual spotting (in about
Physical Exam
No pathognomonic finding
Don’t forget the recto-vaginal exam!
Cul-de-sac nodularity and tenderness
Uterosacral nodularity
Tender, fixed adnexal mass
Uterus fixed and retroverted
Differential Diagnosis
Chronic pelvic inflammatory disease
Recurrent acute salpingitis
Hemorrhagic corpus luteum
Benign or malignant ovarian neoplasm
Ectopic pregnancy
 Sine qua non – sharp, firm, exquisitely tender “barb”
(barbed wire) in uterosacral ligaments
 Ultrasound – adnexal mass of complex echogenicity,
internal echoes consistent with blood
 Definitive diagnosis
 Direct visualization (via laparotomy or laparoscopy)
 Histologic and gross findings consistent with endometrial tissue
 Other tests
 Ca125 - not specific nor sensitive
Appearance of
endometriosis with
back raised lesions of
active endometriosis at
the time of laparascopy
Note: Lesions may be
raised or flat with red,
black or brown
coloration; fibrotic
scarred areas that are
yellow or white in hue;
or vesicle that are pink,
clear, or red.
endometrial cysts
“chocolate cysts”
of the ovary
Endometrial stroma
Endometrial gland
There is no clear
relationship between
stage and frequency
and severity of pain
American Society for Reproductive Medicine revised classification of endometriosis,
1985. (American Fertility Society: Revised American Fertility Society Classification for
Endometriosis. Fertil Steril 43:351,1986)
Key considerations:
Severity of the symptoms
Extent of the disease
Desire for future fertility
Age of the patient
Threat to GI or urinary tract
Management (Medical)
1st line treatment (adequate trial of 3-6 months)
 OCP’s , cyclic or continuous
 Progestins (i.e. Medroxyprogesterone acetate)
 Depression, loss of bone calcium
 To move beyond these, strongly consider laparoscopy to both
diagnose and treat the disease.
Medical treatment
2nd line treatment
 Mirena IUD (levonorgestrel)
 GnRH agonists (Lupron); should not be done without
laparoscopy first; relief of pain does not make the diagnosis of
 Cause hot flashes, vaginal dryness, bone loss
 High dose progestins – suppress gonadotropin release
 Cause abnormal bleeding, depression, fluid retention, nausea
 Danazol – androgenic derivative which suppresses LH and FSH
 “Pseudomenopause” – anolvulation and hypergonadism
 Cause weight gain, hirsutism, acne, deepening voice
 Previously “gold standard,” used rarely now given side effect profile
Management (Surgical)
 Fertility preserving
 Laparoscopic (or rarely, laparotomy) with ablation or excision
of endometrial implants and adhesions
 Endometriomas >3 cm in diameter should be removed
 Most definitive
 Hysterectomy (most often laparoscopic) with ablation or
excision of all endometrial implants and adhesions.
 Removal of ovaries has been traditional, but newer studies
suggest retention of ovaries is reasonable in many cases.
 Always a risk of recurrence!
Bottom Line Concepts
 Typical patient with endometriosis is in her reproductive years, and
 Pathogenesis of endometriosis is not completely understood and
believed to be a combination of factors.
 Characteristic triad of symptoms associated with endometriosis is
dysmenorrhea, dyspareunia, and dyschezia.
 Staging of endometriosis is not clearly associated with frequency and
severity of pain symptoms.
 Appropriate treatment varies widely and should take into consideration
severity of symptoms, extent of disease, and desire for future fertility.
 There is a risk of recurrence of endometriosis throughout a woman’s
 In all women, minimization of menstrual flow and suppression of
ovarian cycling can reduce the risk for endometriosis.
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 38 (p80-81).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 29 (p269-276).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 25 (p298-303).

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