Endometriosis

Definition/diagnostic criteria Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, leading to a chronic, inflammatory reaction. It typically involves the ovaries, fallopian tubes and the tissue lining the pelvis, although it can spread beyond the pelvic organs.

Epidemiology Endometriosis affects approximately 10% of women of reproductive age. It is especially common among women in their 30s and 40s.

Diagnosis Diagnosis is challenging due to the heterogeneity of symptoms and their overlap with other conditions.

Clinical features: Symptoms include dysmenorrhea, deep dyspareunia, non-cyclical pelvic pain and subfertility. There may also be cyclical bowel or bladder symptoms with or without abnormal bleeding or pain. It is crucial to differentiate symptoms from conditions like irritable bowel syndrome and pelvic inflammatory disease.

Investigations: Initial assessment should involve a detailed history and pelvic examination. Ultrasound, preferably transvaginal, is the first-line imaging modality. Laparoscopy remains the gold standard for diagnosis, allowing direct visualisation of endometriotic lesions.

Typical abnormalities include ovarian endometriomas, deep infiltrating endometriosis and peritoneal lesions. Blood tests are not diagnostic but can be used to help rule out other conditions.

Treatment Treatment aims to alleviate symptoms, improve quality of life and address fertility issues.

  • Pain management: First-line treatment for pain includes NSAIDs and hormonal treatments like combined oral contraceptives or progestogens. Gonadotrophin-releasing hormone (GnRH) analogues can be used for short-term relief.
  • Surgical interventions: Surgical options, primarily laparoscopic, include excision or ablation of endometriosis tissue and adhesiolysis. Surgery is more effective than medical treatment for pain relief but with a higher risk of complications.
  • Fertility treatment: In women with endometriosis-associated infertility, surgery or assisted reproduction techniques like in vitro fertilisation (IVF) may be considered.

Prognosis The course of endometriosis is unpredictable. Some women experience gradual improvement, while others may have persistent or worsening symptoms. Long-term management may be necessary, and the condition can impact psychological and social wellbeing. Early diagnosis and tailored treatment are essential for improving the quality of life and managing symptoms effectively.

References

  • European Society of Human Reproduction and Embryology. Endometriosis. 2022
  • NICE Clinical Knowledge Summaries. Endometriosis. 2023.

Published: 30th July 2022 Updated: 8th January 2024

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Pulse Reference is based on the best-selling book Symptom Sorter. The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse. This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.