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Endometriosis

Endometrioses

Presence of Ectopic Uterine Tissue


Presentation

Patients present with one, or usually more of the following signs and symptoms: pelvic pain, lower abdominal and/or back pain [8], dysmenorrhea, dyspareunia, dyschezia, heavy bleeding during and between periods, irregular menstruation and urinary frequency. They may also complain of nausea, bloating and pain during or after exercise. Sometimes the presentation may appear similar to be that of a genito-reproductive tract tumor, in which case a detailed work up can help differentiate the disease from cancer.

Pain
  • […] could be; a score of 1–50 was considered mild pain, 51–80 moderate pain and 81–100 severe pain.[dx.doi.org]
  • […] include: Painful, even debilitating, menstrual cramps, which may get worse over time Pain during or after sex Pain in the intestine or lower abdomen Painful bowel movements or painful urination during menstrual periods Heavy menstrual periods Premenstrual[nichd.nih.gov]
  • VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement.[ncbi.nlm.nih.gov]
  • Patients with peritoneal endometriosis were divided into two different groups depending on their pre-operative pain score: group A had a pain score of 3 or more, while group B a pain score of 2 or less.[ncbi.nlm.nih.gov]
  • No correlation between elevated neurotrophin levels and pain severity appears to exist, suggesting the involvement of other mediators in the modulation of pain.[ncbi.nlm.nih.gov]
Constipation
  • Despite long-term continuous medical treatment, the patient presented 4 years later with impaired digestion consisting in constipation alternating with diarrhea, bloating, dyschesia, and pelvic pain.[ncbi.nlm.nih.gov]
  • This case report is that of a 42-year-old female who presented with a 6-month history of change in bowel habits in favor of increasing constipation. This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss.[ncbi.nlm.nih.gov]
  • Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding.[ncbi.nlm.nih.gov]
  • It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.[mayoclinic.org]
  • […] during periods: severe menstrual cramping, lower back or abdominal pain, painful bowel movements or painful urination Pain during or after sex Excessive bleeding: heavy periods or bleeding or spotting between periods Gastrointestinal symptoms: diarrhea, constipation[health.ucsd.edu]
Abdominal Pain
  • This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss. Examination revealed hyperactive bowel sounds with scant fecal matter on rectal examination.[ncbi.nlm.nih.gov]
  • A 57-year-old woman presented with a chief complaint of worsening abdominal pain over the past 3 months. Imaging studies revealed an appendiceal mass.[ncbi.nlm.nih.gov]
  • KEYWORDS: Chronic abdominal pain; Dysbiosis; Gut permeability; Low grade inflammation[ncbi.nlm.nih.gov]
  • Patients with polypoid endometriosis often present with symptoms related to mass effect rather than classic endometriosis hallmark symptoms such as dyspareunia, dysmenorrhea, and cyclic abdominal pain. Treatment includes surgical resection.[ncbi.nlm.nih.gov]
  • In the setting of a known ectopic pregnancy, severe abdominal pain with clinical concern for rupture is an indication for emergency surgery. In rare cases, appendiceal pathology may occur simultaneously.[ncbi.nlm.nih.gov]
Dyschezia
  • Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility.[ncbi.nlm.nih.gov]
  • She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus. A computed tomography scan showed focal bowel thickening.[ncbi.nlm.nih.gov]
  • Dysmenorrhea was reported to be severe by 66.5% of the sample, dyspareunia by 41.8%, dyschezia by 32.4% and dysuria by 6.5%.[ncbi.nlm.nih.gov]
  • Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding.[ncbi.nlm.nih.gov]
  • It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age.[ncbi.nlm.nih.gov]
Pelvic Mass
  • Following removal of the pelvic masses with laparotomy, the histological exam revealed an endometriosis.[ncbi.nlm.nih.gov]
  • […] et al . (1991) 201 Various No (stage: frequency of pain symptoms) Marana et al . (1991) 206 Infertility, pain, pelvic mass No (stage, type and site of lesions: severity of pain) Ripps and Martin (1991) 59 Infertility, pain, pelvic mass Yes (deep lesions[dx.doi.org]
  • Abstract A 27-year-old woman with swelling left leg, groin pain, and increased serum CA125 level underwent FDG PET/CT to evaluate a pelvic mass revealed by an MRI performed from an outside hospital.[ncbi.nlm.nih.gov]
  • A 40-year-old Asian woman with a 2-year history of lower abdomen pain was admitted to our department with elevated serum cancer antigen (CA) 125 level, weight loss, and pelvic mass from 20 days previously.[ncbi.nlm.nih.gov]
  • There was no evidence of distant metastatic disease on the diagnostic workup, and we performed a laparoscopy to remove the pelvic mass.[ncbi.nlm.nih.gov]
Rectal Pain
  • Other symptoms include: Pain during sexual intercourse Urinary urgency and pain while voiding Lower back or abdominal pain Chronic tiredness Constipation Shooting rectal pain and pain during a bowel movement Pain during ovulation Inflammation of the pelvic[cedars-sinai.edu]
  • The main Gastro-intestinal signs are: Nausea Diarrhoea Blood in stool Bloating Vomiting Rectal pain Rectal bleeding Tailbone pain Abdominal cramping Constipation Sharp gas pains Painful bowel movements For more information on Intestinal endometriosis[endo-resolved.com]
  • Uncommonly, women with rectal pain or bleeding from bowel involvement with endometriosis may have a barium enema examination.[web.archive.org]
  • The most common symptoms are dysmenorrhea, dyspareunia and low back pain that worsens during menses. 9 Depending on the location of the implants, rectal pain and painful defecation may also occur.[web.archive.org]
Low Back Pain
  • It can cause dyspareunia, dysmenorrhea, low back pain and infertility. A definitive diagnosis can be made only by means of laparoscopy.[ncbi.nlm.nih.gov]
  • back pain, and/or fatigue.[medicine.umich.edu]
  • Long-term pelvic or low back pain that may occur at any time and last for 6 months or more.[nlm.nih.gov]
  • Other symptoms may include bloating, lethargy, constipation and low back pain.[patient.info]
Pelvic Girdle Pain
  • Susannah provides assessment and treatment for pelvic pain conditions such as pelvic floor dysfunction, pelvic girdle pain, vulvar and vaginal pain, bladder and bowel dysfunction, and chronic pelvic pain and endometriosis.[bcwomens.ca]
Pelvic Pain
  • Visual presence of endometriosis and decrease in pelvic pain after destruction of lesions.[ncbi.nlm.nih.gov]
  • Median (interquartile range) age at onset of symptoms, at reporting symptoms to a doctor, and at diagnosis in women presenting for pelvic pain and infertility Pelvic pain ( n 180) Infertility ( n 20) Age at onset of symptoms (years) 20.5 (14.0–27.5) 23.5[humrep.oxfordjournals.org]
  • Fifty-one pre-menopausal patients underwent surgical laparoscopy due to chronic pelvic pain, dysmenorrhoea and/or for ovarian cysts. In 44 patients, endometriosis was diagnosed.[ncbi.nlm.nih.gov]
  • Chronic Pelvic Pain in Endometriosis: An Overview Abstract Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world.[dx.doi.org]
  • Abstract Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women.[ncbi.nlm.nih.gov]
Dysmenorrhea
  • Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility.[ncbi.nlm.nih.gov]
  • There is a decreased risk of endometriosis with late age at menarche and an increased risk in women who report an early history of dysmenorrhea.[ncbi.nlm.nih.gov]
  • Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: Results from two independent studies Journal of Endometriosis 2011; 3(4): 188 - 196 Article Type: ORIGINAL ARTICLE DOI:10.5301/JE.2012.9088 Authors Belinda[web.archive.org]
  • The present study aimed to assess the effects of massage therapy, one of the aforementioned methods on endometriosis caused dysmenorrhea. This was a semi-empirical clinical trial.[ncbi.nlm.nih.gov]
  • Dysmenorrhea was reported to be severe by 66.5% of the sample, dyspareunia by 41.8%, dyschezia by 32.4% and dysuria by 6.5%.[ncbi.nlm.nih.gov]
Dyspareunia
  • […] on the Mankoski Pain Scale for analyzing the effect on dysmenorrhea and dyspareunia (n 18), respectively.[web.archive.org]
  • Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility.[ncbi.nlm.nih.gov]
  • Assessment of deep dyspareunia was not available or not reliable in 309 cases.[dx.doi.org]
  • Dysmenorrhea was reported to be severe by 66.5% of the sample, dyspareunia by 41.8%, dyschezia by 32.4% and dysuria by 6.5%.[ncbi.nlm.nih.gov]
  • The most common types of pain are dysmenorrhea, dyspareunia and chronic pelvic pain. Endometriosis can also reduce fertility.[sbu.se]
Adnexal Mass
  • Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhoea and shrinking adnexal masses when used in conjunction with a CHM enema.[ncbi.nlm.nih.gov]
  • The frequency of ovarian endometriosis-complicated pregnancy has almost quadrupled over the last 12 years, to become the most common adnexal mass detected during pregnancy; it was 0.14% (five cases among 3558 deliveries) during the 6-year period from[ncbi.nlm.nih.gov]
  • Ultrasound examination performed at admission revealed a 6 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules.[ncbi.nlm.nih.gov]
  • A set of 38 patients with surgically evaluated adnexal masses, but no hydrosalpinx, were randomly chosen as control subjects.[dx.doi.org]
Pelvic Pain in Women
  • Abstract Abdominal wall endometriosis (AWE) is a rare condition included in the differential diagnosis of an abdominal wall mass and/or pelvic pain in women of reproductive age.[ncbi.nlm.nih.gov]
  • Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000; 4 :CD000387. [ PubMed ] [ Google Scholar ] 9. Weijenborg PT, Ter Kuile MM, Stones W.[ncbi.nlm.nih.gov]
  • Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Human Reprod 2005; 20 :1993-8. [ PubMed ] [ Google Scholar ] 14.[ncbi.nlm.nih.gov]
  • Till and Sawsan As-Sanie, Pharmacological Management of Chronic Pelvic Pain in Women, Drugs, 10.1007/s40265-016-0687-8, 77, 3, (285-301), (2017). Mohamed A.[doi.org]
  • Letrozole (2.5 mg/day) in combination with desogestrel (0.15 mg) and ethinyl estradiol (0.03 mg) has been reported to significantly improve pelvic pain in women with ovarian endometriomas [ 28 ].[doi.org]

Workup

Work up includes a detailed history, physical examination and tests.

Laboratory tests

  • Complete blood count
  • Urinalysis
  • Blood cultures (to rule out STDs)
  • Serum cancer antigen test (Ca-125)
  • Antibody testing against Thomsen-Friedenreich (T) antigen (Gal beta1-3GalNAc) bearing proteins

Imaging 

The following imaging studies may be performed:

  • Transvaginal ultrasound
  • Endorectal ultrasound
  • CT scan and MRI

Other tests

  • Biopsy
  • Pelvic laparoscopy (It is the primary modality for assessing and diagnosing endometriosis).

Test results

Diagnosis is based on physical findings and test results. Imaging studies in particular play an important role in disease identification.

Ovarian Mass
  • We at the Institute, however, council women that if their ovarian masses prove benign, radical surgery would be unnecessary. Often times, during surgery, we find the presence of an endometrioma (Endometriosis of the ovary).[alternativesurgery.com]
  • CONCLUSION: MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging. References 1.[dx.doi.org]
  • Jeong YY, Outwater EK, Kang HK: Imaging evaluation of ovarian masses. Radiographics 2000 Sep-Oct; 20(5): 1445-70 [Medline].[web.archive.org]
  • masses, thickened rectovaginal septum, induration of the cul-de-sac, nodules on the uterosacral ligament, and/or adnexal masses.[merckmanuals.com]

Treatment

Conservative management

It includes the use of analgesics to relieve pelvic and abdominal pain and the use of hormone therapy like the use of Danazol or progesterone. Oral contraceptives have proved to be effective in slowing disease progression. In many women, menopause (natural or surgical) will abate the process [9].

Surgical intervention

If the disease cannot be satisfactorily managed conservatively, it may be treated surgically. Surgical intervention is of two types. The first is called conservative or semi conservative surgical intervention in which reproductive organs are spared. The second type, called radical surgery, involves a total hysterectomy and bilateral oophorectomy as well as adhesiolysis. This type is usually only performed in women past the child bearing age or in women with very serious, grade IV endometriosis.

Prognosis

It is a progressive disease with a high rate of recurrence even after treatment. However, endometriosis has been found to resolve spontaneously in one third of women who are not actively treated [7]. Prognosis depends upon the stage of the disease. It has 4 stages.

  • Stage I: Only superficial lesions and adhesions are present.
  • Stage II: Some superficial as well as deep lesions are present
  • Stage III: Presence of superficial and deep lesions as well as presence of endometriomas in the ovaries
  • Stage IV: All the above findings plus large endometriomas and extensive adhesions.

Etiology

The exact cause of endometriosis is unknown. Several factors have been implicated in its development. The two main theories; metastatic and metaplastic theories have been explained in a later section. Humoral antibodies to endometrial tissue have also been found in sera of women with endometriosis [2]. Some women may also be genetically predisposed to this condition. Overall it is thought to be a collection of several factors, not just one, that ultimately cause this disease. As for why some women may be prone to this disease as opposed to those who are not, studies reveal that it varies on individual-based responses.

Epidemiology

Incidence

Endometriosis is not a common occurrence. Approximately, endometriosis occurs in roughly 4–10% of women [3]. It has a prevalence of 7-10% in the United States.

Age

It is principally a disease of women in their active reproductive life. So it is common in women aged between mid-twenties and early-forties.

Race

There does not appear to be any predilection to a particular race or ethnicity.

Sex distribution
Age distribution

Pathophysiology

The most common site of ectopic endometrial tissue is the ovary. The next most common sites, in decreasing order of frequency are: Uterine ligaments, rectovaginal septum, cul de sac, pelvic peritoneum, large and small bowel, appendix, cervical mucosa, vagina, fallopian tubes and laparotomy scars. Two major theories for the development of endometriosis have been proposed [4], they are:

  • Metastatic theory

According to this theory, there is lymphatic or hematogenous ‘metastasis’ of endometrial tissue to abnormal locations. Retrograde menstruation may be the cause of peritoneal endometriosis, for example.

  • Metaplastic theory

According to this theory, endometrial tissue may itself arise directly from coelomic epithelium at extrauterine sites. This coelomic epithelium is from which the mullerian ducts and ultimately the endometrium itself originates during embryonic development. Under the influence of factors that are still unclear, there may be abnormal production of endometrial gland and stromal cells in sites other than the uterus.

Specific abnormalities that distinguish normal endometrium from endometriotic tissue are highlighted below [5].

  1. Profound activation of inflammatory cascade, characterized by high levels of prostaglandin E2, IL-1B, IL-6 and TNF. 
  2. Marked upregulation of estrogen production mainly due to high levels of the key steroidogenic enzyme aromatase [6].

Prevention

Endometriosis may be prevented or at least slowed by use of birth control pills [10]. Birth control pills act to decrease the production of hormones by the body which are necessary to support the endometrial tissue’s growth and division.

Summary

Endometriosis is defined as ectopic production or occurrence of endometrial tissue in extrauterine sites [1]. Endometrium is the innermost layer lining the uterus. Due to some reasons, as discussed in detail in later sections, this tissue may occur abnormally in extrauterine sites. Commonly, the ectopic tissue consists of both the endometrial glands and the stroma. It may occur anywhere in the body but typically remains within the abdominal and pelvic cavities. It may be confused with cancer so a thorough knowledge of the disease and its manifestation is imperative for proper diagnosis and treatment.

Patient Information

Definition

Endometriosis can be defined as abnormal presence of endometrial tissue (cells of the inner lining of the uterus), outside of the uterus. For example, endometrial tissue may abnormally occur in the ovaries, uterine ligaments, fallopian tubes, peritoneum, as well as other sites.

Cause

There is no known specific cause of endometriosis. It may be genetic or due to some immune dysfunction or it may simply be due to displacement and/or abnormal growth of uterine tissue in sites other than the uterus.

Symptoms

It may be asymptomatic but in symptomatic patients, it presents with painful menstruation, pelvic pain and in severe cases, infertility. Other symptoms include pain during urination or defecation, heavy menstrual bleeding, mid-cycle bleeding, nausea and vomiting and lower back pain.

Treatment

Treatment involves the use of contraceptive pills and painkillers. Surgical intervention may be needed in severe cases.

References

Article

  1. Shepard MK, Mancini MC, Campbell GD Jr, George R. Right-sided hemothorax and recurrent abdominal pain in a 34-year-old woman. Chest. Apr 1993;103(4):1239-40.
  2. Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. Oct 2005;20(10):2698-704.
  3. Markham SM, Carpenter SE, Rock JA. Extrapelvic endometriosis. Obstet Gynecol Clin North Am. Mar 1989;16(1):193-219.
  4. Kruitwagen RF, Poels LG, Willemsen WN, de Ronde IJ, Jap PH, Rolland R. Endometrial epithelial cells in peritoneal fluid during the early follicular phase. Fertil Steril. Feb 1991;55(2):297-303.
  5. Mathur S, Peress MR, Williamson HO, Youmans CD, Maney SA, Garvin AJ, et al. Autoimmunity to endometrium and ovary in endometriosis. Clin Exp Immunol. Nov 1982;50(2):259-66.
  6. Ailawadi RK, Jobanputra S, Kataria M, Gurates B, Bulun SE. Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate: a pilot study. Fertil Steril. Feb 2004;81(2):290-6.
  7. Ferrero S, Esposito F, Abbamonte LH, Anserini P, Remorgida V, Ragni N. Quality of sex life in women with endometriosis and deep dyspareunia. Fertil Steril. Mar 2005;83(3):573-9.
  8. Barbati A, Cosmi EV, Spaziani R, Ventura R, Montanino G. Serum and peritoneal fluid CA-125 levels in patients with endometriosis. Fertil Steril. Mar 1994;61(3):438-42.
  9. Guzick DS, Huang LS, Broadman BA, Nealon M, Hornstein MD. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril. Apr 2011;95(5):1568-73.
  10. Dmowski WP, Kapetanakis E, Scommegna A. Variable effects of danazol on endometriosis at 4 low-dose levels. Obstet Gynecol. Apr 1982;59(4):408-15.

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Last updated: 2019-07-11 22:08