“Endometriosis is a benign and chronic disease that is characterised by the growth of endometrial tissue outside the uterus, inducing a chronic, inflammatory reaction”

Risk Factors
  • Female + age (most common is 20-40 yrs)
  • Family history + genetics
  • Nulliparity
  • Retrograde menstruation (backflow of menstrual fluid containing endometrial cells)
  • Previous pelvic inflammation or infection
  • ­↑ Oestrogen levels
  • Have periods longer than 7 days and cycles shorter than 28 days
Pathophysiology

The exact cause of endometriosis is unknown

  • Retrograde menstruation:
    • During menstruation, endometrial tissue flows backwards → fallopian tubes → abdomen. In some cases, the tissue can then implant in the pelvis → endometriosis
  • Hormonal:
    • ↑ Oestrogen production → encourages growth and shed of endometrial tissue
  • Lymphatic or circulatory spread:
    • Endometrial tissue travel via the lymphatic system or in the bloodstream → implant in areas such as the lungs
  • Metaplasia:
    • The substitution of one type of fully differentiated cell for another within a given tissue. 
    • Metaplasia usually occurs in response to inflammation to enables cells to better adapt to their environment.
    • Potentially explains how endometriosis appears spontaneously inside the body,
    • Potentially explains the appearance of endometriosis cells in women with no womb – or in men who have taken hormone treatments.
  • Immune dysfunction:
    • The immune system may not able to fight off endometriosis.
    • Many women with endometriosis appear to have reduced immunity. It is not known whether this contributes to endometriosis or whether it is as a result of endometriosis.
  • Toxin exposure:
    • Toxins, such as dioxin, can impact the immune and reproductive system
  • Surgical:
    • Endometrial cells can move during a procedure such as a hysterectomy or c-section.
  • Genetic:
    • There may be an inherited component. A woman with a close family member who has endometriosis is more likely to develop endometriosis herself.
Clinical Presentation
  • Asymptomatic
  • Infertility
  • Fatigue
  • Cyclical (pain and GIT symptoms)
  • Dysmenorrhoea
  • Dyspareunia
  • Dyschesia
  • Chronic pelvic pain
  • Endometriosis can be seen in other locations such as the lungs, umbilicus and skin (cells react in the same way as to those in the pelvis)
Investigations
  • Laparoscopy and histological verification is the gold standard
  • Ultrasounds scan
  • Pelvic examination
  • A diagnosis can be categorised as follows:
    • Stage 1: Lesions are minimal and isolated
    • Stage 2: Lesions are mild. There may be several and adhesions are possible.
    • Stage 3: Lesions are moderate, deep or superficial with clear adhesions
    • Stage 4: Lesions are multiple and severe, superficial and deep, prominent adhesions
Management
  • Around 1/3 patients find their symptoms resolve on their own, and recede with menopause
  • Medical:
    • Non­hormonal
      • Simple analgesia (ibuprofen)
    • Hormonal
      • Progestogens
      • Combined oral contraceptive
      • Hormonal IUD
      • Gonadotrophin releasing hormone agonists +/­ add back HRT
  • Surgical:
    • Conservative – aim to destroy all visible endometriosis
      • Diathermy
      • Excision
      • Laser
    • Radical – remove uterus, ovaries and nodules
Complications
  • Up to 50% women present with infertility
  • ­↑ Risk of ovarian cancer or endometriosis-associated adenocarcinoma
  • Ovarian cysts
  • Inflammation → chronic pain
  • Scar tissue and adhesion development
  • Intestinal and bladder complications

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