When endometrial tissue appears outside the lining of the uterine cavity, endometriosis results. Such ectopic tissue is generally confined to the pelvic area, most commonly around the ovaries, uterovesical peritoneum, uterosacral ligaments, and the cul-de-sac, but it can appear anywhere in the body.
This ectopic endometrial tissue responds to normal stimulation in the same way that the endometrium does. During menstruation, the ectopic tissue bleeds, which causes inflammation of the surrounding tissues. This inflammation causes fibrosis, leading to adhesions, which produce pain and infertility.
Active endometriosis usually occurs betWeen ages 30 and 40, especially in women who postpone childbearing; it's uncommon before age 20. Severe symptoms of endometriosis may have an abrupt onset or may develop over many years. This disorder usually becomes progressively severe during the menstrual years but tends to subside after menopause.
Signs and Symptoms
The patient may complain of cyclic pelvic pain, infertility, and acquired dysmenorrhea. The patient typically reports pain in the lower abdomen, vagina, posterior pelvis, and back. This pain usually begins from 5 to 7 days before menses, reaches a peak, and lasts for 2 to 3 days. It differs from primary dysmenorrhea pain, which is more cramplike and concentrated in the abdominal midline. The severity of pain doesn't necessarily indicate the extent of the disease.
Other clinical features depend on the ectopic tissue site. The patient may report a history of infertility and profuse menses (oviducts and ovaries). She may complain of deep-thrust dyspareunia (ovaries and cul-de-sac); suprapubic pain, dysuria, and hematuria (bladder); painful defecation, rectal bleeding with menses, and pain in the coccyx or sacrum (rectovaginal septum and colon); nausea and vomiting that worsen before menses and abdominal cramps (small bowel and appendix).
Palpation may disclose multiple tender nodules on uterosacral ligaments or in the rectovaginal septum. These nodules enlarge and become more tender during menses. Palpation may also uncover ovarian enlargement in the presence of endometrial cysts on the ovaries or thickened, nodular adnexa (as in pelvic inflammatory disease).
Laparoscopy is used to confirm the diagnosis and identify the stage of the disease. A scoring and staging system created by the American Fertility Society quantifies endometrial implants according to size, character, and location. Stage I is minimal disease (0 to 5 points); Stage II signifies mild disease (6 to 15 points); Stage III, moderate disease (16 to 40 points); and Stage IV, severe disease (more than 40 points).
Differential diagnosis of endometriosis is conducted to rule out chronic pelvic inflammatory disease, hemorrhagic corpus luteum cyst, malignant or ovarian neoplasm, ectopic pregnancy, recurrent acute salpingitis, and adenomyosis. These disorders can mimic signs and symptoms of endometriosis.
The stage of the disease and the patient's age and desire to have children are considered in determining the course of treatment.
Conservative therapy for young women who want to have children includes androgens, such as danazol, which produce a temporary remission in Stages I and II. Progestins and oral contraceptives also relieve symptoms. Newer treatment involves gonadotropin-releasing analogues, which suppress estrogen production. This causes atrophic changes in the ectopic endometria. tissue, which allows healing.
Laparoscopy, used for diagnostic purposes, can also be used therapeutically to lyse adhesions, remove small implants, and cauterize implants. Laparoscopy also permits laser vaporization of implants. This surgery is usually followed with hormonal therapy to suppress the return of endometrial implants.
When the patient has ovarian masses, surgery may be needed to rule out cancer. Conservative surgery is possible, but the treatment of choice for women who don't want to bear children or for extensive dsease (Stages III and IV) is a total abdominal hysterectomy with bilateral salpingo-oophorectomy.
Minor gynecologic procedures are contraindicated immediately before and during menstruation.
Endometriosis cannot be prevented. This is in part because the cause is poorly understood. However, long-term use of birth control pills may prevent endometriosis from becoming worse.
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