Endometriosis is a chronic inflammatory condition defined by endometrial stroma and glands found outside of the uterine cavity. The most common sites affected are the pelvic peritoneum and ovaries.
May present incidentally in asymptomatic women, or more commonly in women of reproductive age who complain of chronic pelvic pain and/or sub-fertility.
Clinical suspicion is generally sufficient to initiate therapy, but the diagnosis can only be confirmed by direct visualisation and focused biopsies during laparoscopy.
Treatment options include non-steroidal anti-inflammatories (NSAIDs), combined oral contraceptive pills, progestin-containing compounds, gonadotrophin-releasing hormone (GnRH) agonists and antagonists, danazol (or related androgens), and surgical destruction or excision of lesions. Controlled ovarian hyper-stimulation and IVF may be considered for women with sub-fertility.
Individualised care for women with pelvic pain should incorporate a multi-disciplinary evaluation and treatment plan that focuses on limiting the risk of recurrence and improving quality of life.
Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature. Surgical appearance varies significantly from superficial blebs to infiltrating fibrosis. While direct visualisation confirmed by histological examination remains the gold standard for diagnosis, surgical confirmation of endometriosis is not required before starting therapy.
History and exam
Key diagnostic factors
- presence of risk factors
- chronic or cyclic pelvic pain
- uterosacral ligament nodularity
- pelvic mass
- fixed, retroverted uterus
- unable to attend work or school due to dysmenorrhoea
Other diagnostic factors
- dysuria, flank pain, haematuria
- dyschezia, haematochezia
- reproductive age group
- white ethnicity
- positive family history
- low body mass index (BMI)
- mullerian anomalies
- autoimmune disease
- late first sexual encounter
- previous caesarean section
1st investigations to order
- transvaginal ultrasound
Investigations to consider
- rectal endoscopic ultrasound
- 3D ultrasonography
- MRI pelvis
- diagnostic laparoscopy
immediate fertility not desired: pain without endometrioma or suspected severe/deep disease
immediate fertility not desired: pain with endometrioma or suspected severe/deep disease
immediate fertility desired
M. Jonathon Solnik, MD, FACOG FACS
Professor of Obstetrics, Gynaecology and Medical Imaging by Cross-Appointment
Temerty School of Medicine at the University of Toronto
Head of Gynaecology & Minimally Invasive Surgery
Sinai Health System & Women's College Hospital
MJS is an author of a number of references cited in this topic. He acts as a consultant for AbbVie (manufacturer of depot leuprolide and elagolix), Medtronic, Felix Health and Olympus.
Ari Sanders, MD, FRSCS
Clinical Assistant Professor of Obstetrics and Gynecology
Division of Minimally Invasive Gynecologic Surgery
Department of Obstetrics and Gynecology
Peter Lougheed Centre
University of Calgary
AS acts as a speaker for Abbvie, Hologic, and Bayer. He is an author of one of the articles cited in this topic.
Dr M. Jonathon Solnik and Dr Ari Sanders would like to gratefully acknowledge Dr Sharon M. Jakus, a previous contributor to this topic.
SMJ declares that she has no competing interests.
Joseph S. Sanfilippo, MD, MBA
Department of Obstetrics, Gynecology, and Reproductive Sciences
Division of Reproductive Endocrinology and Infertility
University of Pittsburgh
JSS declares that he has no competing interests.
Justin C. Konje, MBBS, FMCOG, MRCOG, FWACS, MD, MBA
Professor of Obstetrics and Gynaecology
Leicester Royal Infirmary
JCK declares that he has no competing interests.
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- Endometriosis guideline of the European Society of Human Reproduction and Embryology
- Endometriosis clinical practice guideline
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