Endometriosis and adenomyosis
Endometriosis
- Definition. Functional endometrial glands and stroma outside the uterine cavity (Figure 11.1).
- Prevalence. Five to ten percent of women of reproductive age; 30–40% of infertile women; 80% of women with chronic pelvic pain (see Chapter 6).
- Age. Typically diagnosed in women during their 20s. Not found before menarche and characteristically regresses after the menopause.
- Pathogenesis. theories include (1) retrograde menstruation (viable endometrial cells reflux through the tubes during menstruation and implant in the pelvis), (2) celomic metaplasia (multipotential cells of the celomic epithelium are stimulated to transform into endometrium-like cells), (3) hematogenous dissemination (endometrial cells are transported to distant sites), and (4) autoimmune disease (a disorder of immune surveillance that allows ectopic endometrial implants to grow).
Symptoms and signs
- The most common symptoms are pelvic pain and infertility, but many patients are asymptomatic.
- Cyclic pain is the hallmark of endometriosis, including secondary dysmenorrhea (begins before or with menstruation and is maximal at the time of maximal flow), deep dyspareunia (pain with intercourse), pain with defecation, and sacral backache with menses.
- The severity of symptoms does not necessarily correlate with the degree of pelvic disease. Indeed, many women with minimal endometriosis complain of severe pelvic pain.
- Infertility may result from anatomic distortion of the pelvic architecture due to extensive endometriosis and adhesions, but also occurs in women with minimal disease for unknown reasons.
- Common physical findings include a fixed, retroverted uterus, nodularity of the uterosacral ligaments, and enlarged, tender adnexa.
