- 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:
ASRM Classification (American Society for Reproductive Medicine)
The size, depth, and location of endometrial tissue and associated adhesions are evaluated.
|I||Minimal||Isolated implants and no significant adhesions|
|II||Mild||Superficial implants less than 5 cm in aggregate, scattered on the peritoneum and ovaries|
|III||Moderate||Multiple implants, both superficial and invasive. Peritubal and periovarian adhesions may be evident.|
|IV||Severe||Multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions are usually present.|
- 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) →
- Up to one-third of patients are asymptomatic.
- Chronic pelvic pain that worsens before the onset of menses
- Pre- or postmenstrual bleeding
Endometriosis may also be asymptomatic in many women and appear as an incidental finding during surgery performed for another reason!
- Patient history
- Physical examination
- Rectovaginal tenderness
- Adnexal masses
Transvaginal ultrasound (best initial test)
- The uterus is generally not enlarged.
- Evidence of ovarian cysts ()
- Nodules in bladder or rectovaginal septum
- Laparoscopy; (confirmatory test)
- MRI, coloscopy, cystoscopy, or other interventions are potentially indicated if endometrial cells are suspected.
- Common locations of endometriotic implants
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
- Fallopian tubes
- Histologic findings
- See “”
- Definition: benign disease characterized by the occurrence of endometrial tissue within the uterine wall
- Epidemiology: : peak incidence at 35–50 years
- Etiology: The exact etiology is unknown, though some risk factors have been identified:
- Clinical features
Diagnosis is clinical and may be supported by transvaginal ultrasound and MRI findings
- Myometrial wall thickening
- Myometrial cysts
- Linear striations exiting the endometrium
- Poorly defined endomyometrial border
- Increased myometrial heterogeneity
- Histology serves to confirm the diagnosis.
- Diagnosis is clinical and may be supported by transvaginal ultrasound and MRI findings
The differential diagnoses listed here are not exhaustive.
- Mild to moderate pelvic pain without complications
- Severe symptoms
- First-line: laparoscopic excision and ablation of endometrial implants
Second-line: : open surgery with hysterectomy with or without bilateral salpingo-oophorectomy
- Treatment-resistant symptoms
- No desire to bear additional children
- Endometriosis in the uterotubal junction inhibits implantation of the egg: ↑ risk of ectopic pregnancy
- Endometriosis → fibrous adhesions → strictures and entrapment of organs
- Endometriosis may be associated with histologic subtypes of epithelial ovarian cancer.
We list the most important complications. The selection is not exhaustive.