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

Tip

  • Endometriosis: fixed, immobile uterus (due to pelvic adhesion)
  • Adenomyosis: enlarged, boggy, tender uterus
  • 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
  • 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

Endometriosis

  • 1st Line (Pain): NSAIDs and combined oral contraceptives (OCPs).
  • 2nd Line: Progestin-only therapies (e.g., medroxyprogesterone), GnRH agonists (e.g., Leuprolide) to induce a pseudomenopausal state.
  • Surgical: Conservative laparoscopy for resection/ablation of implants (preserves fertility) or definitive surgery (TAH/BSO) for severe, refractory disease.

Adenomyosis

  • Medical: Primarily aimed at symptom control (reducing bleeding/pain).
    • Levonorgestrel-releasing IUD (Mirena) is highly effective.
    • Combined OCPs or progestin-only therapy can also be used.
  • Surgical:
    • Hysterectomy is the only definitive treatment.
    • Uterine artery embolization is an alternative for those wishing to avoid hysterectomy.