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Endometriosis is characterized by the presence of endometrial tissue on the ovaries, fallopian tubes or other abnormal sites, causing pain or infertility. Women are usually 25 to 29 years old at the time of diagnosis.Approximately 24 percent of women who complain of pelvic pain are subsequently found to have endometriosis. The overall prevalence of endometriosis is estimated to be 5 to 10 percent. Clinical evaluationA. Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Differential Diagnosis of Endometriosis - Generalized pelvic pain
- Generalized pelvic pain
- Pelvic inflammatory disease
- Endometritis
- Pelvic adhesions
- Neoplasms, benign or malignant
- Ovarian torsion
- Sexual or physical abuse
- Nongynecologic causes
- Dysmenorrhea
- Primary
- Secondary(adenomyosis,myomas, infection,cervical stenosis)
- Dyspareunia
- Musculoskeletal causes(pelvic relaxation, levator spasm)
- Gastrointestinal tract (constipation,irritable bowel syndrome)
- Urinary tract (urethral syndrome,interstitial cystitis)Infection
- Pelvic vascular congestion
- Diminished lubrication or vaginal expansion because of insufficient arousal
- Infertility
- Male factor
- Tubal disease (infection)
- Anovulation
- Cervical factors (mucus,sperm antibodies, stenosis)
- Luteal phase deficiency
B. Infertility may be the presenting complaint for endometriosis. Infertile patients often have no painful symptoms. C. Physical examination. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination should identify uterosacral, cul-de-sac or septal nodules. Most women with endometriosis have normal pelvic findings.
TreatmentA. Confirmatory laparoscopy is usually required，before treatment is instituted. In women with few symptoms, an empiric trial of oral contraceptives or progestins may be warranted to assess pain relief. B. Medical treatment 1. Initial therapy also should include a nonsteroidal anti-inflammatory drug. - a. Naproxen (Naprosyn) 500 mg followed by 250 mg PO tid-qid prn [250, 375,500 mg].
- b. Naproxen sodium (Aleve) 200 mg PO tid prn.
- c. Naproxen sodium (Anaprox) 550 mg, followed by 275 mg PO tid-qid prn.
- d. Ibuprofen (Motrin) 800 mg, then 400 mg PO q4-6h prn.
- e. Mefenamic acid (Ponstel) 500 mg PO followed by 250 mg q6h prn.
2. Progestational agents. Progestins are similar to combination OCPs in their effects on FSH, LH and endometrial tissue. They may be associated with more bothersome adverse effects than OCPs. Progestins are effective in reducing the symptoms of endometriosis. Oral progestin regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg) . De p o t medroxyprogesterone may be given intramuscularly every two weeks for two months at 100 mg per dose and then once a month for four months at 200 mg per dose. 3. Oral contraceptive pills (OCPs) suppress LH and FSH and prevent ovulation. Combination OCPs alleviate symptoms in about three quarters of patients. Oral contraceptives can be taken continuously (with no placebos) or cyclically, with a week of placebo pills between cycles. The OCPs can be discontinued after six months or continued indefinitely. 4. Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent. Medical Treatment of Endometriosis1.Danazol(Danocrine): - 800 mg per day in 2 divided doses
- Estrogen deficiency,androgenic side
2.Oral contraceptives - 1 pill per day (continuousor cyclic)
- Headache,nausea, hypertension
3.Medroxyprog esterone(Provera) - 5 to 20 mg orally per day
- Same as with other oral progestins
4.Medroxyprog esterone suspension (Depo-Provera) - 100 mg IM every 2 weeks for 2 months; then 200mg IM every month for 4 months or 150 mg IM every3 months
- Weight gain,depression,irregular menses or amenorrhea
5.Norethindron e (Aygestin) - 5 mg per day orally for 2weeks; then increase by 2.5 mg per day every 2 weeks up to 15 mg per Day
- Same as with other oral progestins
6.Leuprolide(Lupron) - 3.75 mg IM every month for 6 months
- Decrease in bone density,estrogen deficiency
7.Goserelin(Zoladex) - 3.6 mg SC (in upper abdominalwall) every 28days
- Estrogen deficiency
8.Nafarelin(Synarel) 400 mg per day: 1 spray in 1 nostril in a.m.; 1spray in other nostril in p.m.; start treatment on day 2 to 4 of menstrual cycle Estrogen deficiency,bone density changes, nasal irritation GnRH agonists. These agents (eg, leuprolide[Lupron], goserelin [Zoladex]) inhibit the secretion of gonadotropin. GnRH agonists are contraindicated in pregnancy and have hypoestrogenic side effects.They produce a mild degree of bone loss. Because of concerns about osteopenia, “add-back” therapy with low-dose estrogen has been recommended. The dosage of leuprolide is a single monthly 3.75-mg depot injection given intramuscularly. Goserelin,in a dosage of 3.6 mg, is administered subcutaneously every 28 days. A nasal spray (nafarelin[Synarel]) may be used twice daily. The response rate is similar to that with danazol; about 90 percent of patients experience pain relief. Surgical treatment1. Surgical treatment is the preferred approach to infertile patients with advanced endometriosis.Laparoscopic ablation of endometriosis lesions may result in a 13 percent increase in the probability of pregnancy. 2. Definitive surgery, which includes hysterectomy and oophorectomy, is reserved for women with intractable pain who no longer desire pregnancy. 2011-07-30
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