Endometriosis

Background

Normal female anatomy with uterus highlighted.

Diagram of uterine blood supply.

• 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
• Mnemonic: 3 D's--dysmenorrhea, dyschezia and dyspareunia
• 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
• Catamenial pneumothorax- rare complication involving recurrent spontaneous pneumothoraces occurring around menses

Differential Diagnosis

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

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervial Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic Pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

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
• Fibroids
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

Evaluation

• 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

• Symptomatic 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

• Discharge with OB/Gyn follow-up

See Also

• Pelvic Pain