“A condition where endometrial tissue grows abnormally, outside of the uterus, within or outside of the pelvic cavity”

  • Intra-pelvic endometriosis sites (more common)
    • Ovaries
    • Fallopian tubes
    • Pelvic peritoneum
    • Uterosacral ligaments
  • Extra-pelvic endometriosis sites
    • GI tract
    • Urinary tract
    • Soft tissues
    • Chest
Risk Factors
  • First-degree relative with endometriosis
  • Prolonged exposure to oestrogen – early menarche or late menopause
  • Elevated exposure to oestrogen
  • Obstruction of menstrual outflow (Müllerian anomalies)
  • Short menstrual cycles (< 27 days)
  • Heavy menstruation that lasts >7 days
  • Low BMI
  • Nulliparity
Aetiology
  • Retrograde menstruation (menstrual blood containing endometrial cells back-flowing into the pelvic cavity via the fallopian tubes)
  • Transformation of other cell types (peritoneal and embryonic) to endometrial cells
  • Adherence of endometrial cells to scar tissue post-surgery (i.e. after Caesarean section)
Pathophysiology
  • Not fully understood – the most widely accepted hypothesis is that endometrial cells are transported from the uterine cavity during menstruation, where they are implanted in ectopic sites
Clinical Presentation
  • Dysmenorrhoea
  • Dyspareunia – can be progressive or chronic
  • Other symptoms vary depending on location of ectopic endometrial tissue
    • Colon – pain when passing stools, abdominal bloating, diarrhoea/constipation during menses, rectal bleeding during menses
    • Bladder – dysuria, haematuria, suprapubic/ pelvic pain, urinary frequency and/or urge incontinence
    • Ovaries – endometrioma formation → rupture/ leakage causes acute abdominal pain
    • Adnexal structures – adhesions resulting in pain or a pelvic mass
  • N/b: pain experienced does not correlate with disease severity
Investigations
  • Diagnosis only possible by laparoscopy
Management
  • Analgesia (analgesic ladder)
  • COCP to limit oestrogen production, which encourages proliferation and shedding of endometrial tissue
  • Progestogens (IUS, contraceptive injection, contraceptive implant) when COCP not suitable
  • Laparoscopic surgical removal of ectopic endometrial tissue
  • Hysterectomy (last resort – symptoms can sometimes return)
Complications
  • Scarring
  • Adhesions (can result in bowel and/or ureter obstruction)
  • Pelvic cysts (can rupture)
  • Endometrioma
  • Thoracic endometriosis (associated with recurrent pneumothoraces)
  • Complications in pregnancy

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