and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definition
Endometriosis is the growth of endometrial tissue outside the uterine cavity.
Endometriosis interna is within the wall of the uterus – also known as adenomyosis
Endometriosis externa is outside the uterus – the pelvic wall, the Pouch of Douglas and the ovaries (called endometriomata) are the commonest sites, but deposits of endometriosis can be anywhere, including the lungs and brain!
Incidence
The true incidence of endometriosis is not known.
It is often associated with subfertility
It is more common in the 20s and 30s
Aetilogy and Pathogenesis
There are several theories for the aetiology:
Retrograde spread of menstruation
Coelomic metaplasia
Lymphatic spread
Vascular spread
But no-one actually knows
The common factor is thought to be a change in immunological tolerance, where the ectopic endometrium is not attacked by the immune system.
The way that endometriosis interferes with fertility is not well understood. The pathogenesis is thought to be through the excessive release of prostaglandins, which in turn interfere with fertilisation and implantation.
Clinical Assessment
History
The most common symptom of endometriosis is pain. Classically this increases as menstruation progresses (in contrast to spasmodic dysmenorrhoea which is at its worst just before the start of, and on the first day of menstruation). The degree of pain is not helpful. Often women with severe endometriosis have minimal pain, whereas some women with minimal endometriosis report debilitating pain, that is not relieved by over-the counter pain medications and prevents them from performing daily activities.
Pelvic pain resulting from endometriosis is not restricted to menstruation. The site of the endometriotic deposits can determine the nature of the pain experienced. For example, endometriosis in close proximity to the bowel can result in pain on defaecation (dyschezia), deposits in the Pouch of Douglas may result in pain during sexual intercourse (deep dyspareunia) and deposits in and around the bladder can cause dysuria and cyclical haematuria.
The pain often radiates through to the back and down the legs.
It may be associated with pre-menstrual spotting, diarrhoea, nausea or vomiting.
A significant number of women with endometriosis will present with heavy menstrual bleeding (HMB). Many women who complain of HMB will have undiagnosed endometriosis. Where there is a suspicion that there may be underlying endometriosis, it is reasonable to undertake a therapeutic trial (see below) as definitive invasive investigations have an element of risk associated with them.
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