Endometriosis

Clinical features

• 5–10% incidence

• Puberty to menopause, peak 25–35 yrs

• Secondary dysmenorrhoea

• Pain may radiate to lower back, legs or rectum

• Gastrointestinal symptoms during menses

• Premenstrual spotting

• Subfertility

• Dyspareunia

• Non-specific pelvic pain

• Heavy menstrual bleeding (menorrhagia)

• Acute pain with rupture of endometrioma

Diagnosis

• Can be made best by direct visual inspection at laparoscopy or laparotomy

• Transvaginal pelvic ultrasound may identify some signs of endometriosis

• Presumed clinical diagnosis may be appropriate

Treatment

• Careful explanation—point out risk of subfertility

• Options include analgesia, hormonal and surgical treatment

Hormonal (aims to suppress disease):

• oral contraceptive or vaginal ring, consider extended or continuous use

• levonorgestrel-releasing IUD 52 mg (Mirena), 5 yrly

• dienogest 2 mg (o) daily

• progestogens (e.g. norethisterone 5–10 mg (o) daily)

• medroxyprogesterone acetate (depot) 150 mcg IM 12 weekly

• GnRH analogues (e.g. goserelin)

Surgical: Surgical measures depend on the patient’s age, symptoms and family planning. Laparoscopy is indicated for diagnosis and excision/ablation of disease, esp. if associated with infertility.

Note: Recurrence is common, hysterectomy may be recommended.