• Clinical science



Endometriosis is a common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue outside the uterus. The etiology of endometriosis is not yet fully established; however, retrograde menstruation is one of several factors involved. Symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Treatment is based on the individual disease manifestation and may either involve the administration of pain relievers and hormonal therapy or surgical removal of endometriotic tissue. Endometriosis tends to recur, but symptoms and disease spread improve after pregnancy in many cases, as well as in menopause.


  • Age of onset: 20–40 years
  • Incidence: 2–10% of all women
  • In the US, endometriosis is more common in white and Asian women than in black and Hispanic women.


Epidemiological data refers to the US, unless otherwise specified.


  • The etiology of endometriosis is not yet fully understood; however, retrograde menstruation seems to play a major role in the pathogenesis of endometriosis.
  • Other contributing factors include:



  • Regardless of where the endometrial tissue is located, it reacts to the hormone cycle; in much the same way as the endometrium and proliferates under the influence of estrogen.
  • Endometriotic implants: including ovaries, fallopian tubes, cervix or less commonly, the extrapelvic organs (e.g., lung or diaphragm)
    • ↑ Production of inflammatory and pain mediators
    • Nerve dysfunction
    • Altered anatomy (e.g., pelvic adhesions) → infertility


Clinical features

Endometriosis may also be asymptomatic in many women and appear as an incidental finding during surgery performed for another reason!



Normally the severity of the findings does not correlate with the severity of symptoms!



  • Endometrial implants present macroscopically as yellow-brown (sometimes reddish-blue) blebs, islands, or pinpoint spots.
  • Gunshot lesions or powder-burn lesions: black, brown, or bluish nodules or cystic structures seen on the serosal surfaces of the ovaries and peritoneum
  • Ovarian endometriomas or chocolate cysts: cyst-like structures that contain blood, fluid, and menstrual debris
  • Histologic findings


Differential diagnoses


The differential diagnoses listed here are not exhaustive.


  • Medical therapy
  • Surgical therapy
    • First-line: laparoscopic excision and ablation of endometrial implants
      • To confirm the diagnosis and exclude malignancy (see “diagnostics” above)
      • If there is a lack of response to medical therapy
      • Treat expanding endometriomas and complications (e.g., bowel/bladder obstruction, rupture of endometrioma, infertility)
    • Second-line: : open surgery with hysterectomy with or without bilateral salpingo-oophorectomy
      • Treatment-resistant symptoms
      • No desire to bear additional children




We list the most important complications. The selection is not exhaustive.