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Endometriosis CLINICAL REVIEW Endometriosis Follow the link from the online version of this article to obtain certi ed continuing 1 2 3 medical education credits Martha Hickey, Karen Ballard, Cindy Farquhar 1 Endometriosis is a relatively common and potentially Department of Obstetrics and SOURCES AND SELECTION CRITERIA Gynaecology, University of debilitating condition affecting women of reproductive We searched Medline and Pubmed, used personal archives Melbourne and the Royal Women’s age. Prevalence is difficult to determine, firstly because of Hospital, Melbourne, Victoria, of references, and consulted with other experts to inform Australia 3052 variability in clinical presentation, and, secondly because this manuscript. When available, data from systematic 2Faculty of Health and Medical the only reliable diagnostic test is laparoscopy, when endo- reviews and randomised controlled trials were used. We Sciences, University of Surrey, metriotic deposits can be visualised and histologically also used expert guidelines such as the recent European Guildford, Surrey, UK Society of Human Reproduction and Embryology (ESHRE) 3 confirmed. Population based studies report a prevalence Department of Obstetrics and consensus.4 Gynaecology, University of of around 1.5% compared with 6-15% in hospital based 1 Auckland, Auckland, New Zealand studies. Endometriosis can be asymptomatic, but those Correspondence to: M Hickey with symptoms generally present early in reproductive What are the causes of endometriosis? [email protected] life and improve after menopause. Symptomatic endome- The pathogenesis of endometriosis is unknown, but lead- Cite this as: BMJ 2104;348:g1752 triosis can result in long term adverse effects on personal ing theories include retrograde menstruation, altered doi: 10.1136/bmj.g1752 relationships, quality of life, and work productivity. A immunity, metaplasia of the germinal epithelium, and European survey of nearly 1000 women indicated that the metastatic spread. Recent studies have also proposed bmj.com average annual cost per woman with endometriosis was stem cell and genetic origins of the disease.5 Consistent Previous articles in this nearly €1000 (£822, $1380) with two thirds of the costs evidence from family and twin based studies supports series from loss of productivity.2 The most important predictor a heritable component to endometriosis, but no specific Ж Management of of healthcare costs is decreased quality of life, and this is gene has been identified, and there are currently no sickle cell disease in the found to be greatest in women with pain, infertility, and genetic tests available. Results of recent genome-wide community persistent disease.3 We have described the clinical evalu- association studies are consistent with a heritable com- (BMJ 2014;348:g1765) ation, implications, and management of endometreiosis ponent in endometriosis.6 Ж Coeliac disease for the primary care provider. (BMJ 2014;348:g1561) What is the natural course of endometriosis? Ж Fibromyalgia What is endometriosis? The natural course of symptomatic endometriosis is dif- (BMJ 2014;348:g1224) Endometriosis is an oestrogen dependent, benign inflam- ficult as almost all adolescent girls report painful periods, Ж Trigeminal neuralgia matory disease characterised by ectopic endometrial glands and it is not possible to exclude a diagnosis of endometrio- (BMJ 2014;348:g474) and stroma, which are often accompanied by fibrosis. These sis without invasive testing. It is not clear whether endo- glands and stroma are typically pelvic but are also found metriosis is a progressive disease and, if so, what factors Ж Management of in other locations, most commonly the bowel, diaphragm, regulate progression. Observational studies in untreated traumatic amputations of umbilicus, and pleural cavity. There are three subtypes of women with infertility suggest that deposits can spontane- the upper limb endometriosis: superficial peritoneal lesions, deep infiltrat- ously regress in up to a third and progress is around 50% (BMJ 2014;348:g255) ing lesions, and cysts (endometriomas) containing blood over 6-12 months.7 It is also unknown if early treatment and endometrium-like tissue. Symptoms vary considerably reduces disease progression. but typically include painful intercourse (deep dyspareunia) and pain before and/or during menstruation (dysmenor- Are any other conditions commonly associated with rhoea), bladder and bowel pain, and chronic pelvic pain. endometriosis? Endometriosis is commonly associated with infertility, with Survey data from selected groups such as the Endometriosis many asymptomatic women being diagnosed with endome- Association report an increase in self reported conditions triosis during investigations for infertility. such as autoimmune disease, chronic fatigue, allergies, asthma, and fibromyalgia among their members. Endome- SUMMARY POINTS triosis is a benign disease, but there is a small but consist- Medical treatment is not recommended for women with endometriosis who are trying to ently reported association between histologically confirmed conceive as it does not improve pregnancy rates and delays fertility endometriosis and clear cell or endometrioid ovarian cancer. The combined oral contraceptive, oral or depot MPA (medroxyprogesterone acetate), A recent meta-analysis has shown that endometriosis about and Mirena (levonorgestrel releasing intrauterine system) are as effective as the GnRH doubles the risk of a diagnosis of ovarian cancer.8 (gonadotrophin releasing hormone) analogues and can be used long term When surgical treatment is being considered, attempt laparoscopic excision or ablation at When should a clinician suspect endometriosis? the time of diagnostic laparoscopy when possible The clinical presentation of endometriosis is highly vari- The cyst wall of endometriomas should ideally be removed instead of drainage and ablation able and relates poorly to the extent of disease (table but treatment can lead to reduced ovarian reserve 1). The key clinical features that should raise suspicion In the five years after surgery or medical treatment, 20-50% of women will experience include pelvic pain, typically starting soon after menarche, recurrence of symptoms and infertility. As many women do not seek treatment for Long term medical treatment (with or without surgery) might reduce recurrence but more infertility, the clinic history should include time to achieve data are needed to define the optimum medical treatment pregnancy or previous infertility. BMJ | 22 MARCH 2014 | VOLUME 348 29 CLINICAL REVIEW 5 Table 1 | Common clinical presentations of endometriosis sis have infertility. The mechanisms linking endometriosis and infertility are poorly understood, and causation is not Symptom Alternative diagnoses to endometriosis Chronic painful periods Adenomyosis, physiological established. Even mild endometriosis can impair fertility, Painful sex (deep dyspareunia) Psychosexual problems, vaginal dryness and severe disease can lead to tubal adhesions, reduced Painful micturition Cystitis ovarian reserve and oocyte and embryo quality, and poor 5 Painful defecation (dyschezia) Constipation, anal fissure implantation. Endometriosis can further impair fertility Chronic lower abdominal pain Irritable bowel syndrome, neuropathic pain, adhesions by disturbing the function of the fallopian tube, embryo Chronic lower back pain Musculoskeletal strain transport, and the eutopic endometrium. Adnexal masses Benign and malignant ovarian cysts, hydrosalpinges Infertility Other causes of infertility What clinical examination is helpful to diagnose endometriosis? Pain Clinical examination cannot provide a definitive diagnosis of Endometriosis is the most common cause of chronic pelvic endometriosis but pain on vaginal examination, tender nod- pain. Pain might not be confined to the pelvis, is not always ules in the posterior fornix, adnexal masses, and immobility cyclical, and is common in the lower back. Typical symptoms of the uterus, particularly fixed retroversion, are diagnostic include dysmenorrhoea, deep dyspareunia (pain on deep pointers. A comparative study between clinical examina- penetration), dyschezia (pelvic pain with defecation), dysu- tion, transvaginal ultrasonography, and magnetic resonance ria (pain with micturition), and chronic pelvic pain. A large imaging (MRI) showed that bimanual examination lacked primary care based case-control study1 showed that 25% of sensitivity and specificity in the diagnosis of endometriosis, women with endometriosis reported dysmenorrhoea to their with less than 50% accuracy. Transvaginal ultrasonography general practitioner in the three years before diagnosis, 24% was superior to MRI in terms of sensitivity (95% v 76%), reported urinary tract symptoms, 11% reported symptoms specificity (98% v 68%), and accuracy (97% v 71%).10 relating to sexual intercourse, 2% reported rectal bleeding or dyschezia, and 16% reported pelvic pain. A total of 58% What is the role of imaging in the diagnosis of endometriosis? of women with endometriosis had abdominopelvic pain. Ultrasonography While these symptoms can also be present in women without A systematic review has shown that transvaginal ultra- endometriosis, they occur much less frequently. Compared sonography can reliably identify endometriomas and can with women without endometriosis, affected women were show adhesions or pelvic fluid,11 and ovarian endometrio- 10 times more likely to report dysmenorrhoea, twice as likely sis has clear and reproducible
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