History

Fact Explanation
Dysmenorrhoea Endometriosis is defined as the presence of endometrial tissue in ectopic sites. Most commonly these are located in the peritoneal cavity with the most common site being the utero-sacral ligaments.[1] Other sites that can be involved are umbilicus, abdominal scars, bladder, rectum, nasal passage etc. These ectopic endometrial tissues undergo cyclical changes with accordance to the menstrual cycle. This leads to repeated bleeding and inflammation at these sites. Thus the patient develops cyclical pelvic pain which is non-colicky & characteristically outlasts the menstrual bleeding.
Heavy menstrual bleeding Due to the presence of endometrial tissue within the myometrium.
Deep dyspareunia The patient may experience deep seated pain during sexual intercourse. This can be due to deposits in the pouch of Douglas or utero-sacral ligaments, fibrosis around the vagina or due to entrapment of an ovary within the pouch of Douglas due to fibrosis.[2]
Chronic pelvic pain Repeated inflammation at the ectopic endometrial sites may lead to healing with fibrosis. This can lead to adhesion formation between adjacent organs.
Lower back pain Due to deposits on the utero-sacral ligament.
Rarely endometriosis in distant sites may present with cyclical local symptoms Deposits in the urinary tract can cause cyclical haematuria, dysuria. Those in the gastrointestinal tract can cause cyclical rectal bleeding, pain on defecation. Those embedded in surgical scars also cause cyclical pain & bleeding. Lung deposits can cause cyclical hemoptysis coinciding with menstruation, while those in the nasal passage can cause cyclical epistaxis.
Subfertility The patient may present with difficulty in conceiving. About 30-40% of patients with endometriosis present with infertility. The etiology of infertility is multi-factorial. In severe disease peri-adnexal adhesions and endometriomas contribute to infertility while in mild disease ovarian factors, tubal factors, sperm factors, dyspareunia may all play a role.[3]
An asymptomatic patient About 2- 50% of patients can be asymptomatic and endometrial deposits are visualized incidentally during a surgical procedure.
There is a significant delay between symptom onset & diagnosis. It is recommended that clinicians should consider the diagnosis of endometriosis in the presence of gynecological symptoms such as secondary dysmenorrhea, chronic pelvic pain, deep dyspareunia etc.[4]
References
  1. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  2. HEIM L.J. Evaluation and Differential Diagnosis of Dyspareunia. American Family Physician, 2001 Apr, 63(8), 1535-1545.
  3. ARMSTRONG C. ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis. American Family Physician. 2011 Jan, 83(1), 84-85.
  4. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx

Examination

Fact Explanation
Vaginal examination : Thickening/ nodularity/ tenderness of the utero-sacral ligament and posterior vaginal fornix. Due to the presence of endometriotic deposits at these sites.
Vaginal examination : Adnexal mass and tenderness Due to the presence of endometriomas.[1] These are endometriotic deposits within the ovary which are composed of altered blood.
Vaginal examination : Fixed retroverted uterus The uterus may be fixed in an abnormal position due to the formation of adhesions.[2]
Speculum examination Rarely lesions situated on the cervix and vagina may be visible.
Rectovaginal digital examination Can be used to detect recto-sigmoidal masses and bowel infiltration. Rectal examination alone can be used for diagnosis in females who have not had previous sexual intercourse and in adolescents.
The evidence on the value of clinical examination findings for the diagnosis of endometriosis is weak. Clinical examination can also be a burden or painful to some patients. Hence the clinician needs to weigh the benefit and burden before examining the patient. [1]
References
  1. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
  2. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.

Differential Diagnoses

Fact Explanation
Fibroids Fibroids are benign proliferation of uterine myometrial smooth muscle (Leiomyoma). Majority are asymptomatic and if symptomatic heavy menstrual bleeding is more a prominent symptom than dysmenorrhoea. Dyspareunia is not usually associated. Vaginal examination will detect a enlarged uterus. Diagnosis is usually confirmed by an ultrasound scan.
Adenomyosis Now considered a separate entity from endometriosis, adenomyosis is the presence of endometrial tissue within the myometrium. The patients are usually diagnosed in the late thirties or forties and they are usually multiparous, in contrast to patients suffering of endometriosis who are commonly nulliparous. Presentation is with severe dysmenorrhoea & menorrhagia. Bimanual vaginal examination will reveal an enlarged tender bulky uterus. Diagnosis is usually made postoperatively but magnetic resonance imaging (MRI) may help preoperative diagnosis.
Pelvic inflammatory disease Chronic pelvic inflammatory disease can present with chronic pelvic pain and menstrual symptoms such as menorrhagia, secondary dysmenorrhoea etc.[1] On vaginal examination the uterus can be fixed in a retroverted position.
Intra-abdominal adhesions[2] Pelvic adhesions secondary to prior abdominal surgery, pelvic inflammatory disease etc may cause chronic pelvic pain. Secondary dysmenorrhoea can be present. A thorough history covering past medical and past surgical history should be taken.
References
  1. GRADISON M. Pelvic inflammatory disease. Amercian Family physician,. 2012 Apr, 85(8), 791-796.
  2. Endometriosis. National institute for health and care excellence, June 2009 [ Viewed on 15 April 2014]. Available form : http://cks.nice.org.uk/endometriosis

Investigations - for Diagnosis

Fact Explanation
Transvaginal ultrasound scan An ultrasound scan may detect endometriomas in gross disease but is ineffective in the presence of mild disease. A transvaginal scan can also be used to detect rectal endometriosis. Another advantage is that it can exclude other differential diagnoses such as fibroids, adenomyosis etc.
Magnetic resonance imaging (MRI) MRI can detect deep seated lesions which are >5mm in size. However MRI is currently not recommended due to its limited effectiveness in diagnosis and low cost effectiveness.
Laparoscopy Laparoscopy is used both as a diagnostic and therapeutic tool.[1] It is considered both successful and safe with a high negative predictive value.Diagnosis depends on the identification of endometrial deposits which can have several morphological appearances – red lesions, white fibrous lesions & black matchstick lesions. The added advantages of laparoscopy include staging of disease, concurrent surgical treatment & obtaining specimens for histology. A positive histology confirms the diagnosis of endometriosis. Deep infiltrating lesions need a histological analysis to exclude the possibility of malignancy.
Use of biomarkers in the diagnostic process Biomarkers are currently not recommended for the diagnosis of endometriosis. Measurement of CA125 levels reveals an increase but provides limited diagnostic information.[2]
References
  1. ARMSTRONG C. ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis. American Family Physician. 2011 Jan, 83(1), 84-85.
  2. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx

Investigations - Screening/Staging

Fact Explanation
Barium enema, transrectal sonography, MRI, intravenous urography (IVU) Additional investigations are recommended to assess the extent of the disease if the history and clinical examination are suggestive of deep endometriosis. The bladder, ureter & bowel are investigated with the above mentioned imaging investigations.[1]
References
  1. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx

Management - General Measures

Fact Explanation
The patient should be educated about the disease.[1] Patient understanding and co-operation is important in the management of endometriosis. The patient should be provided information about the natural course of the disease, the complications and the treatment options.
Analgesia The pain management is important in these patients since the pain can be severe and debilitating. Non-steroidal anti-inflammatory drugs (NSAIDs) are useful to alleviate dysmenorrhoea and pelvic pain.[2]
Treating co-existing diseases Patients with endometriosis can also suffer from irritable bowel disease, constipation etc. Up to 80% of patients may suffer from co-existing diseases.[3] These conditions need to be addressed to achieve overall success in the management.
Psychological support The long drawn and recurrent nature of endometriosis severely affects the patient’s quality of life. Management should aim at both physical and mental wellbeing.
References
  1. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
  2. ALLEN C, HOPEWELL S, PRENTICE A, GREGORY D. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Systamatic Review 2009, CD004753.
  3. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.

Management - Specific Treatments

Fact Explanation
Management plans should be individualized long term strategies. Due to the long natural course of the disease the management plan should be tailored according to the patient’s age, extend of disease, severity of symptoms and patient wishes (fertility or pain control).
Consider medical & surgical treatment options available. Endometriosis is a condition that is estrogen dependent. The basis of treatment is to induce a pseudomenopause. Treating women empirically with COCP or progestogens as a therapeutic trial without a laparoscopic diagnosis is an accepted practice.
Combined oral contraceptive pill. COCP is used either conventionally or continuously in 3/6 month periods.[1] If there is symptomatic relief COCP can be continued indefinitely until pregnancy is desired. Prior to initiation of therapy risk factors for COCP use should be evaluated.
Progestogens Progestogens such as medroxyprogesterone acetate, cerazette, dienogest, cyproterone acetate, norethisterone acetate etc can be used either orally or as subcutaneous/ intramuscular depot preparations. Levonorgestrel releasing intrauterine system can also be used particularly after surgical intervention.
Gonadotrophin-releasing hormone (GnRH) agonists (nafarelin, leuprolide, buserelin, goserelin, triptorelin) An established agent in the treatment of endometriosis.[2] GnRH analogues act by inducing a pseudo-menopause. Routes of administration are intramuscular, subcutaneous depot preparations and intra-nasal sprays. Duration of use is limited for about 3 to 6 months. The main side effects are due to the iatrogenic menopause with presentations such as hot flushes and night sweats. Long term use over 6 months is avoided due to the risk of osteoporosis. For prevention of these adverse effects administration of the drug along with hormone replacement therapy (HRT), so called add back therapy is used.[3]
Ovarian suppressive agents Although effective the use of danazol and gestrinone is limited due to its high side effect profile. Side effects that are seen are weight gain, hirsutism, acne, deepening of voice, alteration in lipid profile etc.
Aromatase inhibitors (letrozole and anastrozole) Patients with rectovaginal endometriosis refractory to other medical & surgical therapy may be treated with aromatase inhibitors. Side effects include vaginal dryness, hot flushes, diminished bone mineral density etc.
Conservative surgical treatment Laparoscopic surgical treatment options can be used to treat endometriosis. Surgical ablation with diathermy, laser vaporization, adhesiolysis, excision of deposits and drainage of the endometriotic cysts with excision of the inner lining are some of the treatment options. Recurrence of disease with conservative surgery is high and this can be minimized in combination with medical treatment.
Definitive surgical management Hysterectomy and bilateral salpingo-oophorectomy with removal of all deposits is considered curative for endometriosis. Curative surgery can be considered in patients with severe progressive disease & who have completed their family. Hormone replacement therapy is delayed for a period of about 6 months to prevent activation of residual deposits.
Management of subfertility associated with endometriosis Medical treatment has not being shown to be effective due to a negative effect on the ovulation. Surgical ablation/ excision/ adhesiolysis can be used in minimal to mild endometriosis with increase in spontaneous pregnancy rates. Success of surgical treatment for infertility in moderate to severe endometriosis is not known. In vitro fertilization may be needed in severe cases.
References
  1. Management of women with endometriosis. European Society of Human Reproduction and Embryology, September 2013 [ Viewed 14 April 2014]. Available from: http://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
  2. Endometriosis: Diagnosis and Management. Society of Obstetricians and Gynaecologists of Canada (SOGC), July 2010 [ Viewed on 14 April 2014]. Available from : http://sogc.org/guidelines/endometriosis-diagnosis-and-management/
  3. ARMSTRONG C. ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis. American Family Physician. 2011 Jan, 83(1), 84-85.