Endometriosis

Endometriosis is where there's ectopic endometrial tissue growth outside of the uterus. It's aetiology isn't fully understood, but some theories are:

• Retrograde menstruation where endometrial lining flows backwards through fallopian tubes into pelvis and peritoneum

• Embryonic cells remain outside uterus and develop in endometrial tissue later

• Lymphatic spread of endometrial cells

• Metaplastic change

Due to its relation to the hormonal cycle, it tends to resolve after menopause.

Presentation

The main presenting symptom is cyclical dysmenorrhoea (cyclical pain). This occurs because the ectopic endometrial cells respond to hormones as normal, so, during menstruation, it’ll also shed its lining and bleed. This causes irritation and inflammation, therefore resulting in this cyclical, dull, heavy/burning pain during menstruation. Over time, this recurrent inflammation can lead to the formation of adhesions, which can cause infertility and chronic, non-cyclical pain (sharp/shooting/pulling).

It can also present with:

• Deep dyspareunia

• Infertility – The localised inflammation can lead to adhesions, which may form around the ovaries and fallopian tubes

• Bowel or urinary symptoms – May be endometrial deposits in bladder or bowel, leading to cyclical haematuria or PR bleeding.

O/E - May see:

• Endometrial tissue visible in vagina (if very severe)

• Fixed cervix on bimanual exam

• Tenderness

Investigations

• TVUS – Often normal

• Diagnostic laparoscopy – Gold standard way of diagnosing, as well as allowing for removal of the deposits

Management

1st line - Paracetamol/NSAIDs

Hormonal options - COCP, Progestogen (e.g. POP) Mirena coil (i.e. IUS)

• This improves symptoms, but not fertility

Surgical option - Excision/Ablation, or Hysterectomy

• Possibility of improving fertility, but may cause scarring