Overview
Definition
The presence of endometrial-like tissue (glands and stroma) outside the uterus, which induces a chronic, estrogen-dependent inflammatory response.
Epidemiology
Affects ~10% of women of reproductive age. A major cause of chronic pelvic pain and infertility.
Etiology & Risk Factors
- Sampson's Theory of Retrograde Menstruation: Menstrual fluid flows backwards through the fallopian tubes into the peritoneal cavity
- Coelomic metaplasia
- Lymphatic/vascular spread
Clinical Symptoms
- The 3 Ds: Dysmenorrhea (painful periods), Dyspareunia (painful intercourse), and Dyschezia (painful defecation)
- Chronic pelvic pain
- Infertility
Clinical Approach
Diagnosis
- Clinical suspicion based on history
- Ultrasound: May show an 'endometrioma' (Chocolate cyst of the ovary)
- Laparoscopy with Biopsy (Gold Standard): Direct visualization of lesions (powder-burn/gunmetal lesions, or clear vesicles)
Management
- First-line (Symptom control): NSAIDs and continuous Combined Oral Contraceptives (OCPs)
- Second-line: GnRH agonists (Leuprolide) to induce a pseudomenopause
- Surgical: Laparoscopic excision/ablation of lesions (improves pain and fertility)
- Definitive (if fertility not desired): Hysterectomy with bilateral salpingo-oophorectomy (BSO)
Complications
- Infertility (due to pelvic adhesions altering anatomy)
- Ovarian endometriomas
- Increased risk of clear cell and endometrioid ovarian cancer