Endometriosis

Background

• Endometriosis results from the presence of endometrial tissue (glands or stroma) implanted outside of the uterus which may result in pelvic pain or infertility.
• The most common location of endometriosis is the ovaries. Other typical locations include the peritoneum, uterosacral ligaments, and retrouterine pouch.
• Associated symptoms, including chronic pelvic pain and subfertility, may be due to the estrogen-stimulated inflammatory response of the endometriotic lesions.
• Women with history of endometriosis may have slight increased risk of ovarian cancer but this risk may be reduced with > 10 years of oral contraceptive use.

Evaluation

• Pelvic pain is the most common symptom associated with endometriosis and is usually chronic.
• Pain is most intense during the late luteal phase and at the beginning of menses.
• Suspect the diagnosis of endometriosis in women with signs and symptoms on history and physical exam, including (Strong recommendation):
  • severe dysmenorrhea unresponsive to nonsteroidal anti-inflammatory drugs
  • pelvic tenderness and nodularity on palpitation of uterosacral ligament and rectovaginal fascia
• Ultrasound is the first-line imaging test to evaluate for suspected endometriosis (Strong recommendation).
• Definitive diagnosis made by laparoscopic visualization of endometrial lesions with histologic confirmation (Strong recommendation).

Management

• Surgical confirmation of endometriosis is not necessary prior to medical treatment of pelvic pain (Strong recommendation).
• Use continuous combined oral contraceptives or progestin alone as first-line therapy for pain associated with endometriosis (Strong recommendation).
• Gonadotropin-releasing hormone (GnRH) agonist with hormone therapy or levonorgestrel-releasing intrauterine device are second-line therapeutic options for pain associated with endometriosis (Strong recommendation).
• Reserve surgical management for women whose pain is unresponsive to medical treatment, have uncertain diagnosis, have acute pelvic findings, or who desire pregnancy in the near future (Strong recommendation).
• In women with endometriosis-associated infertility, laparoscopic treatment of minimal or mild endometriosis is associated with improved pregnancy rates (Strong recommendation).