5-10% prevalence retrograde menstruation is important
Endometriosis is classified as minimal, mild, moderate, and severe. Minimal disease is characterized by isolated implants and no significant adhesions. Mild forms are characterized by superficial implants less than 5 cm in aggregate, scattered on the peritoneum and ovaries. No significant adhesions are present. Moderate forms are characterized by multiple implants, both superficial and invasive. Peritubal and periovarian adhesion may be evident. Severe forms are characterized by multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions are usually present.
Clinical Features and Diagnostic Evaluation
Endometriosis should be considered in any woman of reproductive age who has pelvic pain (Table 1). The most common symptoms are dysmenorrhea, dyspareunia and low back pain that worsens during menses. Depending on the location of the implants, rectal pain and painful defecation may also occur. The stage of endometriosis is not correlated with the presence or severity of symptoms. The diagnosis of endometriosis should be considered especially if a patient develops dysmenorrhea after years of pain-free menstrual cycles. Other causes of secondary dysmenorrhea and chronic pelvic pain (e.g., upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Infertility may also be the presenting complaint. Infertile patients often have no painful symptoms, and their disease is only uncovered in the course of the diagnostic work-up for infertility. The reason for this divergence in clinical manifestations is unknown.
Physical examination should be performed during early menses, when implants are likely to be largest and most tender. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination is required to identify uterosacral, cul-de-sac or septal nodules
Physical findings in women with endometriosis are variable and depend upon the location and size of the implants. There are often no abnormal findings on physical examination. When findings are present, they include:
1. Tenderness when palpating the posterior fornix.
2. Localized tenderness in the cul-de-sac or uterosacral ligaments .
3. Palpable tender nodules in the cul-de-sac, uterosacral ligaments, or rectovaginal septum.
4. Pain with uterine movement Tender, enlarged adnexal masses .
However, most women with endometriosis have normal pelvic findings, and laparoscopy is necessary for definitive diagnosis.
Consider in pelvic pain
- Dysmenorrhea, dyspareunia and low back pain
- May have normal pelvic exam
No single laboratory test has shown reliable clinical utility. Pelvic ultrasonography, computed tomography and magnetic resonance imaging are occasionally used to identify individual lesions, but these modalities are not helpful in assessing the extent of endometriosis.
The optimal way to diagnose endometriosis is by direct visualization of the implant(s). Laparoscopy is the preferred technique since endometriosis is located primarily on the pelvic organs. Biopsy and histologic study of suspicious areas are helpful when the diagnosis is in question
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