Reproductive System & Sexual Health >
Endometriosis
“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