Symptoms

• Main clinical features include:
  • Chronic pelvic pain (found in 70-80% of patients)
  • Dyspareunia (suggests deep posterior infiltration)
  • Infertility (21% prevalence rate)
• Other symptoms may include severe dysmenorrhea, pain on ovulation, noncyclical pelvic pain, cyclical bowel or bladder symptoms w/ or w/o abnormal bleeding or pain, chronic fatigue, or dyschezia
  • In adolescents, endometriosis is the most common cause of secondary dysmenorrhea
• Although it is vital to consider the patient's complaints affecting physical, mental & social well-being, it should be noted that patients w/ endometriosis may be completely asymptomatic (w/ 2-22% prevalence rate)

DIAGNOSIS

• Should include:
  • Age (reproductive year, most commonly at 25-29 yr old)
  • In utero exposure to environmental toxins like diethylstilbestrol which increases the incidence of endometriosis
  • Family history of endometriosis (7x higher risk than w/ no family history)

• Ideally done during early menses because endometrial implants are likely to be largest & deep infiltrating, hence more easily detectable
• Diagnosis is more definite if deeply infiltrative nodules are found on the uterosacral ligaments or in pouch of Douglas, &/or lesions are directly seen in the vagina or cervix
• Note that there may be no abnormal findings on physical exam
• For patients who are not sexually active, a rectal-abdominal exam may be better tolerated than a vag-abdominal exam
• A cotton swab can be inserted into the vagina to document patency & exclude complete or partially obstructive anomalies such as a transverse vaginal septum, imperforate or microperforate hymen, or an obstructed hemivagina

• Pain w/ uterine movement or pelvic tenderness
• Tender, enlarged adnexal masses
• Fixation of adnexa or uterus in a retroverted position

• Urinalysis & urine culture to identify pain originating in the urinary tract (eg cystitis, stones)
• Pregnancy test & tests for sexually transmitted infection (STI) like gonorrhea, chlamydia, when appropriate

• Gold standard for diagnosis, unless lesions are visible in the vagina
  • May also be used for therapeutic purposes
  • Should not be done during or w/in 3 mth of hormonal treatment to avoid under-diagnosis
• Biopsy & histopathologic study of at least one lesion is ideal
  • 3 cardinal features (ie ectopic endometrial glands, ectopic endometrial stroma, & hemorrhage into adjacent tissue) should be present
  • In adolescents, features of endometriosis may be atypical (ie clear vesicles & red lesions)
• A negative laparoscopy does not exclude the diagnosis of endometriosis
• Depending on the severity of the disease found, it is best to remove the endometriotic lesion at the same time
• Differential diagnoses (eg endosalpingiosis, mesothelial hyperplasia, hemosiderin deposition, hemangiomas, adrenal rests, inflammatory changes, splenosis & reactions to oil-based radiographic dyes) can be excluded by biopsy

• Stages based on American Fertility Society (AFS)
  • Minimal disease (stage I) - characterized by isolated implants & no significant adhesions
  • Mild endometriosis (stage II) - consists of superficial implants <5 cm in aggregate, scattered on the peritoneum & ovaries; with no significant adhesions
  • Moderate disease (stage III) - exhibits multiple implants, both superficial & invasive; peritubal & periovarian adhesion may be evident
  • Severe disease (stage IV) - characterized by multiple superficial & deep implants, including large ovarian endometriomas; filmy & dense adhesions are usually present
• Severity of symptoms does not match w/ the above stages