March 20, 2006.
Hedwige Saint Louis, MD, MPH
1. A 17 year old is brought to your office for severe dysmenorrhea which keeps her in bed for 3-5 days every month
during her menses. She started menstruating at age 11 and has always had some menstrual discomfort; however it has
gotten worse over the past year.
• What is the incidence of endometriosis in the general population?
The true incidence of endometriosis is unknown however it s estimated that it is present in 5-10% of reproductive age
women and 25-35% of women with infertility. The prevalence ranges from 25-38% of adolescents with chronic pelvic pain
and 50-70% of adolescents undergoing laparoscopy for pain unresponsive to COC &/ or NSAIDS
• What are the theories on the histogenesis of endometriosis?
There three basic theories:
o Sampson’s theory or transplantation of endometrial tissue via retrograde menstrual flow
o Transformation of totipotential cells into endometrial tissue
o Lymphatic or vascular transport of endometrial tissue fragments
In addition to those three theories, studies have shown a role for impaired cellular immunity as well as genetic
predisposition, i.e. a woman whose sibling has endometriosis has a six-fold increase in risk and the daughter of a woman
with endometriosis has a ten-fold increase in risk compared with the general population
• What are the classical signs of endometriosis?
Classic symptoms include: dysmenorrhea, dyspareunia, dyschezia and/ or a history of unexplained infertility. Unlike adults,
adolescents can have both cyclic and acyclic pain, and they are likelier to experience: bowel problems, i.e. constipation,
painful defecation, rectal bleeding, and urinary symptoms, i.e. dysuria, urgency and hematuria. Adolescents are also less
likely to have endometriomas.
2. A 27 year old nulliparous female presents complaining of dysmenorrhea, and dyspareunia. Her surgical hx is
significant for two previous diagnostic laparoscopies and a TAH/ RSO for pelvic pain and a right-sided endometrioma.
She has successfully used COCs in the past and was on Lupron immediately after her surgery for 6 months.
• What are her treatment options?
o Expectant management would not be an option. In a RCT, 74% of patients with Stage II or III disease experienced
an improvement in their pain symptoms after surgical treatment compared to 20% of those treated expectantly.
Expectant management however has been proven useful in women with Stage I disease.
o Medical management would be an option especially since she has used it in the past. Possible medical treatment
A trial of mefenamic acid is recommended; one study showed that up to 80% of women with dysmenorrhea
responded to Mefenamic acid, 250mg PO QD or Indocin, 25- 50mg PO BID to TID.
Continuous COC have been shown to work in 75% of patient and might be another option.
Danazol, 800mg PO QD, can also be used and has been shown to successfully improve the symptoms of
90% of patients with minimal to moderate disease
Progestins such as medroxyprogesterone acetate are another option. The literature on progestin use for
endometriosis indicates that it is effective for temporary pain relief.
Aromatase inhibitors, i.e. letrozole and anastrozole, may also be used. Both can cause significant bone
loss and should be used in conjunction with progestins or COCs.
Finally the antiprogestional agent Mifepristone is currently being studied as another alternative.
o Surgical treatment, including LSO is also another possible treatment. However the patient should be counseled
about estrogen-deficiency side effects as well as the possibility of recurrent disease, and/ or persistent pelvic pain
even after castration
• How do they differ compared to the previous case?
The 17 year old has not had a trial of medical therapy (3 months of COC+NSAIDs), which would be first line before
proceeding with surgical intervention. Surgical management for adolescents should be restricted to diagnostic laparoscopy
with ablation and resection of lesion, rather than oophrectomy or hysterectomy. Recurrence rate for endometriosis after both
medical and surgical management is significant:
• What is the recurrence rate of disease and/or pain after medical and surgical management?
o GnRH agonists and Danazol therapy: 37% for minimal disease and 74% for severe disease
o 5 years after conservative surgical therapy: 40%
o Risk of recurrent pain and reoperation is respectively 6.1 and 8.1 times greater for women undergoing TAH than
those undergoing TAH/ BSO
3. A 35 year old woman is following up with you after her diagnostic laparoscopy as part of a pelvic pain work up. Her
findings indicate stage II endometriosis according to the ASRM classification, with no tubal abnormalities, and some
superficial ovarian implants, as well as some uterosacral scarring.
• What are the components of the ASRM endometriosis classification system?
ASRM endometriosis classification system components include:
o Presence and size of endometriosis implants on the ovary and peritoneum: < 1cm, 1-3cm, > 3cm
o Presence of posterior cul de sac obliteration: partial or complete
o Presence and type of adhesions and enclosure of the ovary and/ or tube by these adhesions: filmy or dense
• What is the classic endometriosis lesion?
Macroscopically endometriosis lesions are quite variable in appearance: raised flame-like patches, whitish
opacifications, yellow-brown discoloration, translucent blebs, or reddish or reddish-blue irregularly shaped islands. The
peritoneal surface may be scarred or puckered.
Microscopically, endometriotic lesions are similar to intrauterine endometrial tissue with endometriomal glands and
• She has been trying to get pregnant for the past year unsuccessfully, both her work up and her husband’s semen
analysis were normal. How do you counsel her about her fertility?
30-40% of women with endometriosis are infertile and 10-15% of infertile couples have endometriosis as their only
identifiable cause of infertility. There is still no consensus as to the mechanism by which endometriosis causes infertility
in women with minimal disease. Possible mechanisms include: peritoneal, immunologic and ovulatory factors. With ART,
these women have comparable fertilization rates to normal women; however women with endometriosis do have a
higher rate of abnormal implantation.
• What are her infertility treatment options?
Treatment options include:
o Expectant management: the 5 year cumulative pregnancy rate in women with minimal endometriosis and no
treatment is 90%, comparable to women without endometriosis. However two RCT comparing expectant
management vs. surgical tx of infertile endometriosis patients favors surgical tx, and shows an increase monthly
fecundity rate and live birth rate in treated patients
o Medical management with GnRH agonists, progestational agents and Danazol have not been proven to
improve fecundity and fertility
o Surgical management: Tx of mild and moderate disease has been shown to improve both fecundity and live
birth rate, but not for severe disease. ART, using clomiphene or hMGs should be reserved for women with
severe disease or women who fail to see any results after surgery.
1. Glass’s Office Gynecology
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