endometriosis

(en″dō-mē″trē-ō′sĭs)

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[endo- + ¹metro- + osis]
The presence of functioning ectopic endometrial glands and stroma outside the uterine cavity.
SYN: SEE: endomyometritis
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SITES OF OCCURRENCE OF ENDOMETRIOSIS

INCIDENCE
In the U.S., this condition is estimated to occur in 10% to 15% of actively menstruating women between the ages of 25 and 44. Estimates are that 25% to 35% of infertile women are affected. Women whose mothers or sisters have endometriosis are six times more likely to develop the condition than those with no family history.

CAUSES
Although the cause is unknown, hypotheses are that either endometrial cell migration occurs during fetal development or that the cells shed during menstruation are expelled through the fallopian tubes to the peritoneal cavity.

The endometrial tissue invades other tissues and spreads by local extension, intraperitoneal seeding, and lymphatic and vascular routes. The endometrial implants may be present in almost any area of the body although generally they are confined to the pelvic area. Postmenopausal women on estrogen replacement therapy can develop endometriosis. If a woman has had a history of endometriosis, she may develop it when treated with menopausal estrogen replacement. The fallopian tubes are common sites of ectopic implantation. Ectopic endometrial cells respond to the same hormonal stimuli as does the uterine endometrium.

SYMPTOMS AND SIGNS
No single symptom is diagnostic. Patients often complain of dysmenorrhea with pelvic pain, premenstrual dyspareunia, backache in the sacral area during menses, and infertility. Dysuria may indicate involvement of the urinary bladder. Cyclic pelvic pain, usually in the lower abdomen, vagina, posterior pelvis, and back, begins 5 to 7 days before menses, reaches a peak, and lasts 2 to 3 days. Premenstrual tenesmus and diarrhea may indicate lower bowel involvement. Dyspareunia may indicate involvement of the cul-de-sac or ovaries. No correlation exists between the degree of pain and the extent of involvement; many patients are asymptomatic.

DIAGNOSIS
Although history and findings of physical examination may suggest endometriosis, and imaging studies (transvaginal ultrasound) may be helpful, definitive diagnosis of endometriosis and staging requires laparoscopy, which allows direct visualization of ectopic lesions and biopsy.

TREATMENT
Medical and surgical approaches may be used to preserve fertility and to increase the patient's potential for achieving pregnancy. Pharmacological management includes the use of hormonal agents to induce endometrial atrophy by maintaining a chronic state of anovulation.

Surgical management includes laparotomy, lysis of adhesions, laparoscopy with laser vaporization of implants, laparotomy with excision of ovarian masses, or total hysterectomy with bilateral salpingo-oophorectomy and removal of aberrant endometrial cysts and implants to encourage fertility. The definitive treatment for endometriosis ends a woman's potential for pregnancy by removal of the uterus, fallopian tubes, and ovaries.

IMPACT ON HEALTH
The cyclic bleeding and local inflammation surrounding endometrial implants may cause fibrosis, adhesions, and tubal occlusion. Infertility may result.

PATIENT CARE
Providing emotional support and meeting informational needs are major concerns. The patient is encouraged to verbalize feelings and ask questions. The woman is prepared physically and emotionally for any surgical procedure. Adolescent girls with a narrow vagina or small vaginal meatus are advised to use sanitary napkins rather than tampons to help prevent retrograde flow. Because infertility is a possible complication of endometriosis, a patient who wants children is advised not to postpone childbearing. An annual pelvic examination and Papanicolaou test are recommended.

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THE ICEBERG OF ENDOMETRIOSIS

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