Endometriosis

Background

• Endometrial glands and stroma at extrauterine sites, generally in the pelvis but can be anywhere in the body
• The condition is a common, benign, estrogen-dependent disorder
• Can be associated with debilitating symptoms

Clinical Features

• Classic symptoms: dysmenorrhea, pelvic pain, dyspareunia, and infertility
• Other symptoms may include: include abnormal uterine bleeding, low back pain, or chronic fatigue
• Endometriosis is commonly detected as an asymptomatic incidental finding on pelvic ultrasound or during a surgical procedure

Differential Diagnosis

• Ectopic pregnancy
• Pelvic inflammatory disease
• Interstitial cystitis
• Adenomyosis
• Ovarian neoplasms
• Pelvic adhesions
• Irritable bowel syndrome
• Colon cancer
• Diverticular disease

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand disease, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Anticoagulants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Hypothyroidism
• Polycystic Ovary Syndrome
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Leiomyoma (Fibroid)
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

Diagnosis

• History of symptoms described above
• Exam with tenderness when palpating posterior fornix
• Labs are not generally useful
• Pelvic ultrasound is the first-line study
• Laparoscopy for definitive diagnosis

Management

• Expectant management
• Analgesia
• Hormonal medical therapy
  • OCP's, GnRH agonists, progestins, danazol, aromatase inhibitors
• Surgical intervention - conservative (retain uterus and ovaries) or definitive (TAH-BSO)

Disposition

Referral to gynecology