Endometriosis is a condition where endometrium-like tissue grows outside of the uterine cavity. It is the second most common gynaecological condition amongst women of reproductive age in the UK, with approximately 10% of them affected and typically taking an average of 7.5 years from first symptoms to diagnosis.
Endometriosis has no single definitive cause. Multiple theories have been put forward, but it is likely to be multifactorial, including genetic factors and retrograde menstruation (where blood flows backwards into the pelvis instead of out of the vagina during menstruation).
The most common locations for endometriosis are the pelvis, ovaries, peritoneum, uterosacral ligaments, and the pouch of Douglas.
Risk factors for endometriosis include:
Clinical presentation is variable, with some women experiencing severe symptoms and others having none at all.
Typical symptoms of endometriosis may include:
Other important areas to cover in history include:
Typical findings on abdominal examination may include:
Typical findings on pelvic/bimanual examination may include:
A normal pelvic or abdominal examination does not exclude endometriosis.
Differential diagnoses to consider in the context of endometriosis include:
Relevant bedside investigations include:
Relevant laboratory investigations include:
Consider a transvaginal ultrasound scan which can be helpful to show endometriomas, however, a normal scan does not exclude endometriosis.
Diagnostic laparoscopy is the gold standard investigation. However, this is still an invasive procedure with a small risk of major complications (e.g. bowel perforation).
Pelvic MRI (magnetic resonance imaging) and serum CA-125 (cancer antigen) are not routinely recommended investigations. MRI may be requested by specialist teams to look for deep endometriosis.
Endometriosis can be a chronic disease affecting women throughout their reproductive lives. Some patients may have complex needs and require long term support.
Therefore, it is important to assess each individual's circumstances, symptoms, priorities, desires for fertility, background and physical, psychosexual, and emotional needs.
If fertility is a priority, management of endometriosis-related subfertility should have multidisciplinary team involvement with input from a fertility specialist.
Initial management of endometriosis may include a short trial of paracetamol or non-steroidal anti-inflammatory alone or in combination, and hormonal treatment (combined contraceptive pill or progesterone). Referral to gynaecology service should also be considered if initial management is not effective, not tolerated or contraindicated, or there are severe, persistent or recurrent symptoms or pelvic signs of endometriosis.
Surgical management options depend on the impact on fertility. If fertility is not a priority, laparoscopic treatment of peritoneal endometriosis with hormonal treatment used as an adjunct for deep endometriosis (involving bowel, bladder or ureter) or a hysterectomy performed laparoscopically (with or without oophorectomy) in combination with surgical management can be considered. If fertility is a priority, excision or ablation of endometriosis, adhesiolysis and removal of endometriomas can be offered to improve chances of spontaneous pregnancy.
Endometriosis can have a significant impact on women's quality of life and daily living with repercussions for their relationships, sexuality, work productivity, fitness and mental health. It is important to holistically support women with endometriosis.
Resources are available like Endometriosis UK who help women take back control by providing vital support services, reliable information and a community for those affected.
Complications of endometriosis may include:
