Endometriosis is the presence of endometrial tissue outside the lining of the uterine cavity. Such ectopic tissue is generally confined to the pelvic area, most commonly around the ovaries, uterovesical peritoneum, uterosacral ligaments, and cul-de-sac, but it can appear anywhere in the body. This ectopic endometrial tissue responds to normal stimulation in the same way that the endometrium does. During menstruation, the ectopic tissue bleeds, which causes inflammation of the surrounding tissues. This inflammation causes fibrosis, leading to adhesions that produce pain and infertility.
Active endometriosis usually occurs between ages 20 and 40; it’s uncommon before age 20. Severe symptoms of endometriosis may have an abrupt onset or may develop over many years. This disorder usually becomes progressively severe during the menstrual years; after menopause, it may subside.
The mechanisms by which endometriosis causes symptoms, including infertility, are unknown. The main theories to explain this disorder are:
❑ transtubal regurgitation of endometrial cells and implantation at ectopic sites
❑ coelomic metaplasia (repeated inflammation may induce metaplasia of mesothelial cells to the endometrial epithelium)
❑ lymphatic or hematogenous spread to explain extraperitoneal disease.
Endometriosis occurs in 10% of women during the reproductive years. Prevalence may be as high as 25% to 35% among infertile women. A woman with a mother or sister with endometriosis is six times more likely to develop endometriosis than a woman without this familial history.
The classic symptom of endometriosis is acquired dysmenorrhea, which may produce constant pain in the lower abdomen and in the vagina, posterior pelvis, and back. This pain usually begins from 5 to 7 days before menses reaches its peak and lasts for 2 to 3 days. It differs from primary dysmenorrheal pain, which is more cramplike and concentrated in the abdominal midline. However, the pain’s severity doesn’t necessarily indicate the extent of the disease.
Other clinical features depend on the location of the ectopic tissue:
❑ ovaries and oviducts: infertility and profuse menses
❑ ovaries or cul-de-sac: deep-thrust dyspareunia
❑ bladder: suprapubic pain, dysuria, hematuria
❑ small bowel and appendix: nausea and vomiting, which worsen before menses, and abdominal cramps
❑ cervix, vagina, and perineum: bleeding from endometrial deposits in these areas during menses.
The primary complications of endometriosis are infertility and chronic pelvic pain.
Pelvic examination may suggest endometriosis. Palpation may detect multiple tender nodules on uterosacral ligaments or in the rectovaginal septum in one-third of patients. These nodules enlarge and become more tender during menses. Palpation may also uncover ovarian enlargement in the presence of endometrial cysts on the ovaries or thickened, nodular adnexa (as in pelvic inflammatory disease). Laparoscopy must confirm the diagnosis and determine the disease’s stage before treatment is initiated. Endometriosis is classified in stages: Stage I, mild; Stage II, moderate; Stage III, severe; and Stage IV, extensive.
Treatment varies according to the disease’s stage and the patient’s age and desire to have children. Conservative therapy for young women who want to have children includes androgens, such as danazol, which produce a temporary remission in Stages I and II. Progestins and hormonal contraceptives also relieve symptoms. Gonadotropin-releasing hormone agonists, by inducing a pseudomenopause and, thus, a “medical oophorectomy,” may cause a remission of disease and are commonly used. However, medical therapy remains inadequate.
When ovarian masses are present, surgery must rule out cancer. Conservative surgery includes laparoscopic removal of endometrial implants with conventional or laser techniques and presacral neurectomy for severe dysmenorrhea. The treatment of choice for women who don’t want to bear children or for extensive disease is a total abdominal hysterectomy with bilateral salpingo-oophorectomy.
❑ Because infertility is a possible complication, advise the patient who wants children not to postpone childbearing.
❑ Recommend an annual pelvic examination and Papanicolaou test to all patients.
Review other book chapters online related to Endometritis:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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