Overview

• Growth of endometrial tissue outside the uterus.
  • Most common affected sites → recto-uterine pouch (pouch of doughlas), vesico-uterine pouch, utero-sacral ligaments, ovaries, fallopian tubes.
• Affects up to 10% of women of reproductive age.
• Aetiology → theory that during menstruation the endometrial lining flows backward, through the fallopian tubes (retrograde menstruation).
• Risk Factors → early menarche, FHx, nulliparity, prolonged menstruation (>5 days), short menstrual cycles (<28 days).

Making Diagnosis

Clinical Features

• Cyclical or chronic pelvic pain → occurs before or during menstruation. Cells of endometrial tissue outside the uterus also shed during mesntruation and bleed. This causes irritation and inflammation of the tissues around the sites of endometriosis.
  • Typically around 4 days before period.
• Dysmenorrhoea.
• Deep dyspareunia.
• Subfertility.
• Urinary Symptoms → dysuria, urgency, haematuria.
• Bowel Symptoms. (Dependent on where extra tissue is growing).
  • Dyschezia → painful bowel movements
• O/E → endometrial tissue visible in the vagina on speculum, fixed cervix on bimanual examination, tenderness in the vagina/cervix/adnexa. FIXED AND RETROVERTED IMMOBILE UTERUS (due to adhesion formation).

Investigations

• Laparoscopy → gold standard for diagnosis. Definitive diagnosis with biopsy of lesions during laparoscopy.
  • Allows for the direct visualisation of endometrial tissue within the abdominal cavity. It also allows for the instantaneous treatment of any endometrioid tissue or adhesions that are seen.
  • Do TVUSS in first-instance as less-invasive (may show ovarian endometriomas or the involvement of structures such as the uterosacral ligament).
• ‘Chocolate’ Cyst (aka Ovarian Endometrioma) → cysts filled with menstrual blood. Sign of endometriosis in the ovaries. Unilocular with ground-glass echoes.
  • Association with clear cell carcinoma.