Molecular structure pattern

Endometriosis Disease Summary

Key Presenting Symptoms

  • Severe dysmenorrhea

    Main clinical feature

  • Chronic pelvic pain

    Found in 70-82% of patients

  • Dyspareunia

    Suggests deep posterior infiltration

  • Infertility

    21% prevalence rate

Assessment Workflow

View More on Disease Algorithm

  1. 1. History

    Ask about age, in utero exposure to diethylstilbestrol, family history, menstrual cycle, and endometriosis symptoms.

  2. 2. Physical examination

    Perform abdominal inspection and palpation, rectovaginal examination, and assess uterine mobility, position, and size.

  3. 3. Initial imaging

    Use transvaginal sonography as the first-line imaging tool to examine suspected endometriosis.

  4. 4. Definitive evaluation

    Laparoscopy is the gold standard for diagnosis unless lesions are visible in the vagina; biopsy and histopathology of at least one lesion is ideal.

  5. 5. Classify disease

    Use rASRM staging and the Enzian system when classifying laparoscopic findings.

Diagnosis

  • Diagnosis is supported by severe dysmenorrhea, chronic pelvic pain, dyspareunia, infertility, or other cyclical pelvic symptoms.
  • Physical examination may show pelvic tenderness, uterosacral ligament tenderness, adnexal masses, or rectovaginal septum induration.
  • Laparoscopy is the gold standard for diagnosis unless lesions are visible in the vagina.
  • Biopsy and histopathologic study of at least one lesion is ideal; the three cardinal features are ectopic endometrial glands, ectopic endometrial stroma, and hemorrhage into adjacent tissue.
  • The rASRM score classifies disease as minimal, mild, moderate, or severe; the Enzian system adds deep infiltrating and retroperitoneal involvement.[2][11][23]
View More on Diagnosis

Differential Diagnosis

Differential diagnosisKey Distinguishing Feature
Primary dysmenorrhea[41]
Adenomyosis[41]
Uterine fibroids[41]
Cervical stenosis[41]
Obstructive genital tract[41]
View More on Differential Diagnosis

Diagnostics: Lab Tests and Imaging

Test / AssessmentClinical Purpose
Urinalysis and cultureIdentify urinary tract pain sources[11]
Pregnancy testUsed when appropriate[11]
STI testsTest for gonorrhea and chlamydia when appropriate[11]
Transvaginal sonographyFirst-line imaging for suspected endometriosis[11]
MRIAlternative after negative or indeterminate ultrasound[11]

Pharmacological Management

Treatment roleTherapyKey note
First-lineCombined oral contraceptivesFirst-line for pelvic pain secondary to endometriosis.[1][2]
First-lineProgestinsUsed for chronic pain; effective reduction in pain.[1][2]
Second-lineGnRH agonistsFor patients who failed COCs or progestins, or had recurrence.[1][2]
Second-lineGnRH receptor antagonistsIndicated for moderate to severe pain associated with endometriosis.[2]
OptionAromatase inhibitorsFor women refractory to medical or surgical treatment.[2]
OptionDanazolUse if other medical therapies are unavailable; not long term.[1][2]

Dosage Guidelines

  • Danazol

    Antigonadotropins

    Dosage: 200-800 mg/day PO divided 6-12 hourly started at menstrual cycle onset x 3-6 months up to 9 months

  • Elagolix

    Anti-GnRH

    Dosage: 150 mg PO 24 hourly x up to 24 months; women with dyspareunia: 200 mg PO 12 hourly x up to 6 months

  • Buserelin

    GnRH analogues

    Dosage: 1 spray (150 mcg) in each nostril 8 hourly or 200-500 mcg SC 24 hourly; start on day 1 or 2 of the menstrual cycle; duration: 6 months

  • Dienogest

    Progestogens

    Dosage: 2 mg PO 24 hourly taken at the same time each day without interruption; start on any day of the menstrual cycle

View More on Drug Summary

Non-pharmacological management

  • Laparoscopy is recommended when medical treatment is not tolerated or has failed.
  • Laparoscopy is recommended when drug therapies are contraindicated.
  • Surgery may be used to confirm the diagnosis and provide treatment for pain relief or improved fertility.
  • Hormonal suppression may be given prior to surgery to decrease implant size and reduce the extent of surgery required.
  • Post-op medical therapy may be used to treat residual disease and delay recurrence.[1][2]

Specialist Referral

Referral indication: Persistent symptoms after medical therapy

Source-stated referral: referred for a laparoscopy[2]

Referral indication: Symptoms severe, incapacitating, or acute

Suggested specialist: Gynecologist[2]

Referral indication: Advanced or invasive disease affecting bowel, ureters, bladder, or pelvic nerves

Suggested specialist: Gynecologist[2]

References

  1. ACOG Committee on Practice Bulletins - Gynecology. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010 Jul;116(1):223-236. doi: 10.1097/AOG.0b013e3181e8b073. PMID: 20567196
  2. Allaire C, Bedaiwy MA, Yong PJ. Diagnosis and management of endometriosis. CMAJ. 2023 Mar;195(1):E363-E371. doi: 10.1503/cmaj.220637. PMID: 36918177
  3. Daniilidis A, Grigoriadis G, Dalakoura D, et al. Transvaginal ultrasound in the diagnosis and assessment of endometriosis - an overview: how, why, and when. Diagnostics (Basel). 2022 Nov 23;12(12):2912. doi: 10.3390/diagnostics12122912. PMID: 36552919
  4. Haas D, Shebl O, Shamiyeh A, et al. The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Acta Obstet Gynecol Scand. 2013 Jan;92(1):3-7. doi: 10.1111/aogs.12026. PMID: 23061819
  5. Nasir L, Bope ET. Management of pelvic pain from dysmenorrhea or endometriosis. J Am Board Fam Pract. 2004 Nov-Dec;17(Suppl):S43-S47. PMID: 15575029
View More on References