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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
  • Therefore symptoms of endometriosis include severe reoccurring pain in the pelvic area as well as lower back and abdominal pain.[ncbi.nlm.nih.gov]
  • There can be a pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity, pain during bowel movements and urination, during general bodily movement like exercise, pain from standing or walking, and pain with[en.wikipedia.org]
  • Pain associated with appendiceal endometriosis can mimic other intra-abdominal pathology.[ncbi.nlm.nih.gov]
  • There is no relationship between the frequency of dysmenorrhoea or non-cyclic pelvic pain and the disease stage; although these pain symptoms are significantly more prevalent in cases with both ovarian and peritoneal endometriotic implants.[ncbi.nlm.nih.gov]
  • Symptoms It may be asymptomatic but in symptomatic patients, it presents with painful menstruation, pelvic pain and in severe cases, infertility.[symptoma.com]
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]
  • […] 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]
  • When acute abdominal pain with hemoperitoneum occurs in non-gravid reproductive age women, with no positive findings for liver or spleen lesions, a possible spontaneous rupture of utero-ovarian vessels related to the presence of deep infiltrating endometriosis[ncbi.nlm.nih.gov]
  • Transmural involvement of intestinal endometriosis is extremely rare and is usually associated with recurrent abdominal pain.[ncbi.nlm.nih.gov]
  • We present the case of a 37-year-old nulliparous woman who presented for diffuse abdominal pain and vomiting; she was diagnosed with complete ileocecal obstruction due to an endometriosis nodule in association with bilateral ovarian endometriosis lesions[ncbi.nlm.nih.gov]
Dyschezia
  • 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]
  • 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]
  • A 45-year-old white female with a 4-month history of chronic pelvic pain, dyschezia, and dysmenorrhea, refractory to hormonal therapy was referred to our unit.[ncbi.nlm.nih.gov]
  • . - Dyspareunia or painful intercourse - Infertility - Fatigue - Cyclical intestinal complaints: periodic bloating, diarrhoea or constipation - Cyclical dyschezia, painful or difficult defecation. - Cyclical dysuria, painful urination - Cyclical hematuria[endometriosis.ie]
Lower 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]
  • Women may have constant pelvic or lower abdominal pain as well.[obgyn.ucla.edu]
  • The most common sign of endometriosis is severe pelvic (lower abdominal) pain. It may occur occasionally or constantly, and it may be associated with a girl's period.[kidshealth.org]
  • Other symptoms that can be related to endometriosis include lower abdominal pain , diarrhea and/or constipation , low back pain , chronic fatigue irregular or heavy menstruation, painful urination , or bloody urine (particularly during menstruation).[medicinenet.com]
Pelvic Mass
  • Following removal of the pelvic masses with laparotomy, the histological exam revealed an endometriosis.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • mass) and adhesions in the ovary Stage IV — Severe evidence with all of the above and large endometriomas and adhesions Living with endometriosis Simple steps that can help ease the pain of endometriosis include: Rest, relaxation, and meditation Warm[cedars-sinai.edu]
  • Surgical Treatment Surgical management is often performed for acute pain, symptoms that have failed medical management, presence of infertility, or presence of a pelvic mass.[innovativegyn.com]
Skin Lesion
Low Back Pain
  • back pain, and/or fatigue.[medicine.umich.edu]
  • Clinical findings Often accompanied by dysmenorrhoea, cyclical pain, low back pain, thigh pain, hypermenorrhoea, repeated miscarriages, infertility, bleeding per rectum or bladder. Regional swelling with vicarious ectopic bleeding parallels menses.[medical-dictionary.thefreedictionary.com]
  • Symptoms of endometriosis Endometriosis symptoms Chronic pelvic pain Severe menstrual cramps Painful intercourse Heavy or irregular periods Low back pain Painful bowel movements or urination Gastrointestinal symptoms such as bloating, constipation, diarrhea[womentowomen.com]
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
  • Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women.[ncbi.nlm.nih.gov]
  • This cross-sectional study aimed to assess the prevalence of endometriosis in women who were referred for Diagnostic Laparoscopy Unit due to infertility or pelvic pain between January 2012 and January 2013 and compare the symptoms and laparoscopic signs[ncbi.nlm.nih.gov]
  • Endometriosis is a frequent cause of pelvic pain and subfertility in women of reproductive age.[ncbi.nlm.nih.gov]
  • We present a case of a pregnant woman who came to the emergency room at 25 weeks with acute abdominal and pelvic pain.[ncbi.nlm.nih.gov]
  • J Endometr Pelvic Pain Disord 2017; 9(4): 223 - 231 DOI: 10.5301/jeppd.5000310 Article Type: REVIEW Yiğit Çakıroğlu , Rafael Confino , Mary Ellen Pavone J Endometr Pelvic Pain Disord 2017; 9(4): 232 - 238 DOI: 10.5301/jeppd.5000309 Article Type: REVIEW[j-endometriosis.com]
Dysmenorrhea
  • 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]
  • In conclusion, the expression of MMIF, HIF-1α, and VEGF in the serum and endometrial tissues may be used to assess the stage of EM and the severity of dysmenorrhea.[ncbi.nlm.nih.gov]
  • These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms-such as dysmenorrhea and dyspareunia.[ncbi.nlm.nih.gov]
  • A 33 year-old infertile female presenting with dysmenorrhea was found to have a bladder mass by pelvic ultrasound. Cystoscopy revealed a protruding tumor from the posterior bladder wall, and endometriosis was highly suspected.[ncbi.nlm.nih.gov]
  • Presence of extra-uterine endometrial-like tissue is responsible for non-specific symptoms such as chronic pelvic pain, dysmenorrhea, dyspareunia, dyschesia and sometimes infertility.[ncbi.nlm.nih.gov]
Dyspareunia
  • 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]
  • These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms-such as dysmenorrhea and dyspareunia.[ncbi.nlm.nih.gov]
  • Presence of extra-uterine endometrial-like tissue is responsible for non-specific symptoms such as chronic pelvic pain, dysmenorrhea, dyspareunia, dyschesia and sometimes infertility.[ncbi.nlm.nih.gov]
  • A 44-year-old para two woman presented with worsening dysmenorrhea and dyspareunia. She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus.[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 Pain in Women
  • 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. It usually occurs after pelvic surgery, most commonly caesarean section.[ncbi.nlm.nih.gov]
  • Pelvic pain in women with endometriosis depends partly on where endometrial implants of endometriosis are located. Deeper implants and implants in areas of high nerve density are more apt to produce pain.[medicinenet.com]
  • Endometriosis Related Articles Facts about and Medical Definition of Endometriosis Endometriosis is a common disorder of the female reproductive organs and is the leading cause of chronic pelvic pain in women.[emedicinehealth.com]
Adnexal Mass
  • 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]
  • MRI has a greater specificity for the diagnosis of endometriomas than the other non-invasive imaging techniques 1 and thus has a role to play in the evaluation of adnexal masses , as well as assessing for response to medical therapy (see below) potentially[radiopaedia.org]
  • Sonography of adnexal masses. Ultrasound Clinics . January 2007;2(1):133-53: Kinkel K, Chapron C, Balleyguier C, Fritel X, Dubuisson JB, Moreau JF. Magnetic resonance imaging characteristics of deep endometriosis.[emedicine.medscape.com]

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]
  • Surgical management includes laparotomy, lysis of adhesions, laparoscopy with laser vaporization of implants, laparotomy with excision of ovarian masses, or total hysterectomy with bilateral salpingo-oophorectomy and removal of aberrant endometrial cysts[medical-dictionary.thefreedictionary.com]
  • These include, but are not limited to, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, pelvic adhesions (scar tissue), ovarian masses, uterine abnormalities, fibromyalgia, malabsorption syndromes and, very rarely, malignancies[healthywomen.org]

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: 2018-06-22 12:27