Endometriosis



Pathophysiology of Endometriosis

endometriosis is:

1) presence of benign endometrial tissue outside of uterine cavity
2) most commonly found in posterior cul-de-sac (pouch of Douglas)
3) also found on ovaries, rectosigmoid, bladder, uterosacral ligaments and very occasionally at distant sites such as
lungs, bones, umbilicus
4) pathogenesis is uncertain

Signs and Symptoms

1) pelvic pain
2) dysmenorrhea (esp. before onset of menstrual flow)
3) dyspareunia
4) pelvic pain
5) constipation
6) intestinal obstruction
7) palpable tender nodules on uterosacral ligament on rectal/vaginal exam
8) cervical deviation owing to mass effect
9) posteriorly fixed uterus on speculum exam
10) amount of ectopic tissues does not correlate with symptoms

Characteristic Test Findings

Radiology – ultrasound can show enlarged cystic ovaries up to 15 cm with material inside (chocolate cysts)

Histology/Gross Pathology

1) ectopic deposits of endometrial stroma or glands
2) grossly, deposits look like bluish red nodules
3) sometimes deposits collect hemosiderin and look like “powder burns”
4) if monthly bleeding occurs, deposits can be surrounded by fibrotic tissue

endometriosis photoshop Endometriosis

Endometriosis deposit seen on bowel mucosa

Associated Conditions

1) decreased fertility
2) pelvic fibrosis
3) hematuria (if bladder affected)
4) increased incidence in Turner’s syndrome

Biochemistry

1) deposits can undergo cyclic hormonal stimulation with monthly bleeding 2) endometriosis (unlike tissue in uterus) has aromatase chtochrome P450

Inheritance/Epidemiology

1) most common between ages of 30 and 40 years 2) occurs in 3% of women of childbearing years 3) rare after menopause 4) found incidentally in 20% of gynecological surgery

Treatment

1) suppressive hormone therapy
2) laparoscopic laser ablation
3) hysterectomy with removal of ovaries bilaterally in severe cases
4) angiogenesis inhibitors may have a role

Tips for USMLE

1) if a 34 year old woman has severe menstrual cramping 1-2 days before her period starts and has been trying unsuccessfully to get pregnant for the past 4 years, think endometriosis

2) if question mentions chocolate cysts or powder burn tissue, think endometriosis

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