Endometriosis: Clinical sciences

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Introduction0:00–1:05

Endometriosis is when endometrial stroma or glands are found outside of the endometrium. Normally, endometrial cells are only present within the endometrial lining of the uterine cavity, which thickens and sheds during each menstrual cycle.
The exact cause of endometriosis is complex but there are three theories. First, it’s believed to be due in part to retrograde menstruation leading to attachment of endometrial glands and stroma to the peritoneum.
Second, distant lesions might be established by the hematogenous or lymphogenous route. And third, the theory of coelomic metaplasia says that cells of the visceral and parietal peritoneum undergo metaplastic change into endometriotic lesions.
Endometriosis is commonly diagnosed in reproductive-age biological women, specifically those with a history of chronic pain and infertility.

Patient presentation1:05–5:04

Let’s dive into the steps to take when a patient presents with a chief concern suggesting endometriosis. The initial approach involves obtaining a focused history and physical exam as well as a pelvic ultrasound.
Patients might report chronic pelvic pain; dysmenorrhea, meaning painful periods; menorrhagia, or heavy menstrual bleeding; as well as deep dyspareunia, or painful intercourse; low back pain during periods, and bowel and bladder symptoms like diarrhea and dysuria.
An easy way to remember common symptoms of endometriosis is to think of the 4 Ds: dysmenorrhea, dyspareunia, dyschezia, and dysuria.
Other common historical findings include infertility and a family history of endometriosis. In fact, patients with an affected first-degree relative have nearly a 7 to 10 times increased risk of developing endometriosis themselves!
Additionally, risk factors for developing endometriosis include early menarche specifically occurring before age 11; shorter cycles, commonly less than 27 days; and heavy, prolonged periods.
Here’s a clinical pearl! Be sure to rule out sexually transmitted infections like gonorrhea or chlamydia, which can be associated with chronic pelvic pain due to chronic pelvic inflammatory disease.When it comes to the physical exam, findings suggesting endometriosis include abdominal or pelvic tenderness, uterosacral ligament nodularity, and occasionally, palpation of an adnexal mass.
Here’s another clinical pearl! The uterosacral ligaments are thick, supportive bands of fibrous tissue that connect the uterus to the sacrum.
When endometrial tissue grows and implants here, it can form nodules or lumps which may be palpated on physical examination.
These findings are associated with deep infiltrating endometriosis. Alright, back to diagnosis.
Ultrasound may help support your suspicion for endometriosis and will also help rule out other causes of chronic pelvic pain or infertility.
Characteristic findings include a pelvic or adnexal mass, such as an ovarian endometrioma or deep infiltrating endometriosis.
Endometriomas appear as cysts that contain low-level, homogeneous internal echoes consistent with old blood. Keep in mind that in some cases, ultrasound may not reveal any overt physical abnormalities.
In fact, in the vast majority of times, the ultrasound will be normal. This does not rule out the possibility of endometriosis.
Ultrasound is used only to identify other potential causes of pelvic pain, there is not one specific ultrasound finding required for the diagnosis.
Now, if the patient has a positive history and physical exam, plus or minus the characteristic imaging findings, you should suspect endometriosis!
Here’s a clinical pearl! Most diagnoses of endometriosis are made on clinical findings including history, physical exam, and possibly ultrasound.
A definitive diagnosis of endometriosis can be made by performing a laparoscopy, biopsying suspicious lesions, and confirming the presence of endometrial glands and stroma histologically.
That being said, laparoscopy is reserved for cases where the presenting complaint is infertility, or in cases of failed medical management.
In fact, treatment should not be delayed to perform surgery and you can still treat your patient as having endometriosis without an official biopsy.
Alright, now that we have diagnosed endometriosis, let’s discuss treatment. Your approach to management is tailored to the patient’s individual goals, so start by assessing their desire for pregnancy.

Endometriosis Management5:04–7:05

If your patient wants to become pregnant immediately, start by prioritizing their pain and provide analgesia with NSAIDs.
Additionally, pelvic floor physical therapy can be considered, which can aid in treating pelvic floor dysfunction, as well as strengthening the pelvic muscles.
Also, consider an infertility workup to assess and treat factors affecting the patient’s ability to conceive. Finally, consider performing a laparoscopy, which will ensure the correct diagnosis through biopsy and allow for excision of any suspected endometriosis.
Here are a couple of clinical pearls! In terms of surgically treating an endometrioma, excision of the cyst wall is superior to simple drainage and ablation, as the latter has an increased risk of reformation.
Now, if an initial surgery for endometriosis-associated infertility is unsuccessful, in vitro fertilization is the next best option rather than reoperation.
Ok back to your patient who may or may not want a future pregnancy! If they express a future desire for pregnancy or indicate that they do not wish to become pregnant, several treatment options are available.
You may consider pelvic floor physical therapy for all patients to address coexisting pelvic floor dysfunction. The first line treatment for endometriosis is medical management.
Similar to those desiring immediate fertility, you’ll start off by providing analgesia with NSAIDs. In addition, recommend starting a combined oral contraceptive pill, or OCP.
Additionally, extended-cycle OCPs may further help treat any pain associated with withdrawal bleeding. Now, assess the patient’s response.

Response to treatment7:05–11:27

If it is adequate, and the patient is happy with their management plan, continue routine follow-up to monitor their progress and ensure ongoing well-being.
However, if the patient continues to be symptomatic and has an inadequate response, consider alternative options for treatment, including other medical options and surgical management.
For medical management, GnRH agonists are second-line to OCPs. Generally, they are used for a short time period, often as bridge therapy, while a patient awaits more definitive surgical intervention.
It’s important to counsel your patients on common side effects of GnRH agonists, like vaginal dryness, hot flashes, and bone loss.
Additionally, the use of add-back therapy, or replacement progestin with norethindrone, is recommended to prevent permanent bone loss.
Unfortunately, once a patient stops their GnRH agonist their symptoms often return. Another option to consider is a GnRH antagonist, like elagolix or relugolix.
These medications are paired with a small dose of estrogen and progestin to help alleviate the common side effects of vaginal dryness and hot flashes.
Additionally, they can be used for up to 2 years, but similar to GnRH agonists, symptoms typically return once a patient stops the medication.
Keep in mind that GnRH agonists and antagonists are not birth control, so you should always discuss family planning goals with your patient, and prescribe contraception as indicated!Other options include progestins like medroxyprogesterone acetate, which has been shown to be equivalent to GnRH agonists in reducing pain with substantially less bone loss.
The levonorgestrel intrauterine system can also be used to treat endometriosis-associated pelvic pain; however, it’s not FDA-approved for this specifically and patients should be counseled as such.
Other medical options, such as danazol, which is an androgenic drug, can also be used. However, danazol has a significant side effect profile, including acne, hirsutism, and myalgias, thereby limiting its use clinically.
Switching gears, surgical management includes laparoscopy, which can be diagnostic and therapeutic with lesion removal via laser vaporization, fulguration with cautery, or surgical excision.
Diagnosis can be confirmed through a biopsy of the area or areas of suspicion, and removal of endometrial implants has been associated with decreased pain.
Here’s a clinical pearl! The appearance of endometrial implants on laparoscopy varies greatly.
Some lesions appear as “powder-burn” or black and blue in nature, while others may be red or even clear. Keep in mind that the degree of patient’s pain may not correlate to what is seen at laparoscopy.
Pain is a reflection of how deeply an implant is embedded, not necessarily the quantity of lesions present. Back to treatment, if the response continues to be inadequate…other options can be considered.
For medical management, Aromatase inhibitors like anastrozole and letrozole are another option in cases of chronic pain unresponsive to standard medical and surgical management.
Typically these drugs are used with a progestin or combined oral contraceptive to lessen follicle-stimulating hormone release, which can potentially cause chronic ovarian stimulation.
For those who do not desire a future pregnancy, and whose response continues to be inadequate, hysterectomy with bilateral salpingo-oophorectomy is available and considered definitive therapy.
The risks and benefits of surgical menopause must be carefully discussed with the patient for “shared decision making” before pursuing definitive therapy.
In patients with normal ovaries, a hysterectomy with ovarian conservation and removal of endometriotic lesions should be considered instead.
Alright, as a quick recap… Endometriosis is characterized by endometrial tissue growth outside of the uterine cavity. Diagnosis involves a focused history, physical exam, and pelvic ultrasound.

Review11:27–12:24

Treatment options depend on the patient's reproductive plans and include medical and surgical approaches. For patients who desire immediate pregnancy, analgesia is recommended to manage pain.
For patients who plan pregnancy in the future or those who do not desire pregnancy, medical management involves NSAIDs and combined oral contraceptive pills.
Alternative options include GnRH agonists or antagonists, progestins, aromatase inhibitors and laparoscopy. For definitive treatment, surgical management with a hysterectomy is an option, though only for those not planning future pregnancies.