Epidemiology

Etiology

Pathophysiology

• In endometriosis, endometrial tissue occurs outside of the uterus.
  • It's adenomyosis if in uterus.
• Common locations of endometriotic implants include:
  • Pelvic organs
    • Ovaries: most common site; often affected bilaterally
    • Rectouterine pouch
    • Fallopian tubes
    • Bladder
    • Cervix
  • Peritoneum
  • Extrapelvic organs (e.g., lung or diaphragm): less commonly affected
• 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 result in:
  • ↑ Production of inflammatory and pain mediators
  • Anatomical changes (e.g., pelvic adhesions) → infertility

Clinical features

General

• Chronic pelvic pain that worsens before the onset of menses
• Infertility
  • Endometriosis causes inflammation and adhesions that can change pelvic anatomy, altering egg quality and impairing implantation. 25–50% of infertile women have endometriosis.
• Dysmenorrhea
• Pre- or postmenstrual bleeding
• Dyspareunia

Intestines

• Dyschezia
• Diarrhea
• Constipation
• Rectal bleeding

Diagnostics

Pathology

• Normal endometrial glands
• Normal endometrial stroma
• Preponderance of hemosiderin laden macrophages due to cyclic hemorrhages into endometriomas

Differential diagnosis

Adenomyosis

• Definition: benign disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
• Epidemiology: peak incidence at 35–50 years
• Clinical features
  • May be asymptomatic
  • Dysmenorrhea
  • Abnormal uterine bleeding
  • Chronic pelvic pain, aggravated during menses
  • Globular, uniformly enlarged uterus that is soft but tender on palpation
    • Differ from Uterine leiomyoma, which shows irregularly enlarged, firm uterine
• Diagnostics
  • Diagnosis is clinical and may be supported by transvaginal ultrasound and MRI findings
    • Asymmetric myometrial wall thickening
    • Myometrial cysts

Pathology

Macroscopic findings

• Ovaries
  • Gunshot lesions or powder-burn lesions
    • Black, yellow-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

Treatment

• Mild to moderate pelvic pain without complications
  • Empiric treatment with NSAIDs and continuous hormonal contraceptives
  • NSAIDs alone if pregnancy is desired
  • Synthetic androgens (e.g., danazol)
• Severe symptoms: GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs
  • OCPs are to avoid hypoestrogenic side effects