Endometriosis

September 5, 2011

Endometriosis is the presence of tissue, which should exist only inside the uterus (endometrial glands and endometrial stroma), at sites outside the uterus. This disease affects many women in the reproductive age group, and chronic pelvic pain associated with endometriosis is one of the most common symptom complexes that gynecologists are required to treat. Although its etiology has not been conclusively identified, it is generally believed to involve abnormalities in the immune system. It is unclear whether this is causal or simply a response to abnormal implants.

Endometriosis is associated with painful periods (dysmenorrhea), painful intercourse (dyspareunia), noncyclical pelvic pain, and infertility. There are also a myriad of associated symptoms, especially those that involve the gastrointestinal tract. Chronic pelvic pain associated with endometriosis can be difficult to treat because of the large number of patients who have a relapse. The diagnosis of endometriosis can only be made by a specialized procedure involving a small tube that allows visualization inside the uterus/pelvis (laparoscopy). Blood (serum) markers and pelvic imaging techniques such as ultrasound lack sufficient sensitivity and specificity to allow a diagnosis.

Most endometrial deposits are found in the pelvis (ovaries, peritoneum, ligaments and structures around the uterus, vagina, and rectum). Deposits outside of the pelvis, including those in the umbilicus, and previous surgical wounds are uncommon. The physical appearance of endometriosis at laparoscopy can be quite varied. The diagnosis is usually made visually at laparoscopy, but cellular (histologic) analysis is important as well.

SYMPTOMS AND DIAGNOSIS

Patients with endometriosis can present with a wide variety of symptoms and signs. Typically, dysmenorrhea, dyspareunia, and noncyclic lower abdominal pain are common. Gastrointestinal symptoms such as constipation, diarrhea, and abnormal urge to defecate (tenesmus), similar to irritable bowel syndrome, are also common. Urinary symptoms are less common but pain with urination may occur. Patients with infertility may not have any pain that they consider manageable. The diagnosis in these patients is made at the time of diagnostic laparoscopy for infertility. Many diagnostic tests have been proposed. The most popular is a blood test called CA-125. Imaging modalities are generally not useful.

Intensive efforts are under way to develop noninvasive methods of diagnosing endometriosis. Recently, encouraging reports suggest that specialized tests of blood or fluid in the abdomen (serum and peritoneal fluid cytokines) might be helpful in the nonsurgical diagnosis of endometriosis.

LAPAROSCOPIC ASSESSMENT

Diagnosis of endometriosis can be suggested by history and examination, but definitive diagnosis can be made only by visualization with a small tube (laparoscopy) or conventional exploratory surgery (laparotomy). Endometriosis is a heterogeneous disease that ranges in severity from minimal to severe. The most commonly used classification of endometriosis is according to the American Society for Reproductive Medicine (formerly American Fertility Society). In this system, the surgeon assigns a certain number of points for disease identified at laparoscopy. This is based on the area and depth of endometrial implants in the abdominal cavity (peritoneum) or ovary, as well as the extent of fibrous growths (adhesions) on the ovaries, tubes connecting ovaries to uterus (fallopian tubes), and related tissues. The patient is then assigned a stage of I-IV. Definitive diagnosis of ovarian endometriomas should be confirmed by microscopic cellular (histopathologic) examination.

Endometriosis remains a difficult clinical enigma. The clinician has to rely on the clinical history and physical exam. Generally, diagnostic tests and imaging modalities are not useful and diagnostic laparoscopy is still the “gold” standard. However, empirical medical therapy for chronic pelvic pain is acceptable before diagnostic laparoscopy, in some circumstances. Firstline treatment for painful symptoms could be medical or surgical. In infertility, surgery has been shown to be effective while medical suppressive therapy has not. Assisted conception has a primary role in moderate and severe disease.

In the hands of the experienced laparoscopic surgeon, advanced endometriosis can be managed effectively with short convalescence and excellent long-term results. The primary care physician can manage most endometriosis-associated symptoms. Consultation with a specialist is recommended in certain circumstances.

MANAGING PAIN ASSOCIATED WITH ENDOMETRIOSIS

In a double-blind randomized clinical trial, it was found that two thirds of patients will have significant relief from surgical management of endometriosis. More dramatic relief was found from surgical management of advanced endometriosis rather than early disease. Medical therapy has been found to provide a similar response rate.

MANAGING INFERTILITY ASSOCIATED WITH ENDOMETRIOSIS

It is well established that a relation exists between endometriosis and infertility. In advanced cases of endometriosis, fertility is affected as a consequence of the anatomical distortion of the pelvis caused by adhesions or ovarian cysts, or both. Unlike an infection, endometriosis does not damage the lining (luminal epithelium) of the fallopian tube and thus surgery is more likely to be successful. In minimal or mild cases of endometriosis, the exact nature of the relation between the disease and infertility is unclear. In a randomized clinical trial to assess surgical management of early stage disease in patients with infertility, it was found that the pregnancy rate can double. Medical suppressive therapy has not been shown to increase pregnancy rates. Pregnancy rates with endometriosis-associated infertility may be improved by laparoscopic surgery for moderate to severe disease. Advanced endometriosis is characterized by extensive pelvic distortion that can be corrected by surgical treatment.

SEE ALSO: Infertility, Laparoscopy

Suggested Reading

  • Al-Azemi, M., Bernal, A. L., Steele, J., Gramsbergen, I., Barlow, D., & Kennedy, S. (2000). Ovarian response to repeated controlled stimulation in in-vitro fertilization cycles in patients with ovarian endometriosis. Human Reproduction, 15, 72-75.
  • Bedaiwy, M. A., Falcone, T., Sharma, R. K., Goldberg, J. M., Attaran, M., Nelson, D. R., et al. (2002). Prediction of endometriosis with serum and peritoneal fluid markers: A prospective controlled trial. Human Reproduction, 17, 426-431.
  • Jerby, B. L., Kessler, H., Falcone, T., & Milsom, J. W. (1999). Laparoscopic management of colorectal endometriosis. Surgical Endoscopy, 13, 1125-1128.
  • Jones, K., & Sutton, C. (2000). Endometriomas: Fenestration or excision? Fertility and Sterility, 74, 846-848.
  • Ling, F. W. (1999). Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstetrics and Gynecology, 93, 51-58.
  • Lundorff, P., Hahlin, M., Kallfelt, B., Thorburn, J., & Lindblom, B. (1991). Adhesion formation after laparoscopic surgery in tubal pregnancy: A randomized trial versus laparotomy. Fertility and Sterility, 55, 911-915.
  • Marcoux, S., Maheux, R., & Berube, S. (1997). Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. New England Journal of Medicine, 337, 217-222.
  • Mol, B. W., Bayram, N., Lijmer, J. G., Wiegerinck, M. A., Bongers, M. Y., van der Veen, F., et al. (1998). The performance of CA-125 measurement in the detection of endometriosis: A meta-analysis. Fertility and Sterility, 70, 1101-1108.
  • Nezhat, C., Nezhat, F., Nezhat, C. H., Nasserbakht, F., Rosati, M., & Seidman, D. S. (1996). Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility, 66, 920-924.
  • Nezhat, C. H., Seidman, D. S., Nezhat, F. R., & Nezhat, C. R. (1998). Long-term outcome of laparoscopic presacral neurectomy for the treatment of central pelvic pain attributed to endometriosis. Obstetrics and Gynecology, 91, 701—704.
  • Redwine, D. B. (1999). Ovarian endometriosis: A marker for more extensive pelvic and intestinal disease. Fertility and Sterility, 72, 310-315.
  • Singh, M., Goldberg, J., Falcone, T., Nelson, D., Pasqualotto, E., Attaran, M., et al. (2001). Superovulation and intrauterine insemination in cases of treated mild pelvic disease. Journal of Assisted Reproduction and Genetics, 18, 26-29.
  • Sutton, C. J., Ewen, S. P., Whitelaw, N., & Haines, P. (1994). Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertility and Sterility, 62, 696-700.
  • Tulandi, T., & al-Took, S. (1998). Reproductive outcome after treatment of mild endometriosis with laparoscopic excision and electrocoagulation. Fertility and Sterility, 69, 229-231.

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