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Emergent Treatment of Endometriosis 

  • Author: Turandot Saul, MD; Chief Editor: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE  more...
 
Updated: Dec 29, 2015
 

Background

Endometriosis is a gynecologic disorder that is frequently encountered in the emergency department (ED) as well as in the outpatient setting. Because it is enigmatic, endometriosis can present as a diagnostic and therapeutic challenge for emergency physicians in their approach to the female patient with pelvic pain.[1, 2, 3]

Prior to ascribing a patient's abdominal or pelvic pain to endometriosis, the clinician should consider other important causes of such pain, including ectopic pregnancy, pelvic infection, and ovarian torsion. Patients may also have concomitant endometriosis and inflammatory bowel disease (stricturing Crohn disease).[4]

The most common sites of involvement in endometriosis, as seen on laparoscopic examination, are as follows, in descending order:

  • Ovaries
  • Posterior cul-de-sac
  • Broad ligament
  • Uterosacral ligament
  • Rectosigmoid colon
  • Bladder
  • Distal ureter

Go to Endometriosis for complete information on this topic.

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Laboratory Studies

In the ED setting, few laboratory tests prove to be valuable in the diagnosis of endometriosis.

A complete blood count (CBC) with differential may help to differentiate pelvic infection from endometriosis and to assess the degree of blood loss, if any.

Urinalysis and urine culture should be sent if urinary tract infection (UTI) is in the differential diagnosis.

Cervical Gram stain and cultures should be considered, because sexually transmitted diseases (STDs) can also cause pelvic pain and infertility.

Beta human chorionic gonadotropin (HCG) can rule out pregnancy and its complcations.

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Imaging Studies

Radiography

Routine radiographs are not recommended unless other disease entities requiring these studies are in the differential diagnosis.

Ultrasonography

Endometriosis can be assessed by either transvaginal ultrasonography or endorectal ultrasonography. The ultrasonographic features of endometriomas vary from simple cysts to complex cysts with internal echoes to solid masses, usually devoid of vascularity.[5]

Magnetic resonance imaging

Magnetic resonance imaging (MRI) offers a superior combination of 3D imaging with high-resolution special and temporal resolution, low observer dependency, no radiation exposure, and none of the risks associated with iodinated contrast agents.

With dynamic contrast-enhanced MRI, dynamic changes in MR signal intensity in selected tissues can be detected. Some of the newer generation contrast agents can be loaded with specific antibodies that allow for targeted imaging.

MRI has a higher sensitivity for detecting pelvic masses than ultrasonography but is limited in identifying diffuse pelvic endometriosis.

Computed tomography scanning

Using computed tomography (CT) scanning, endometriomas may appear as cystic masses, but their appearance is nonspecific, and CT scanning should not be relied on for diagnosis.

Complications of endometriosis, including bowel obstruction and hydronephrosis, may be seen on CT scans.

Hysterosalpingography

Hysterosalpingography may reveal tubal occlusion or periadnexal adhesions.

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Procedures

Laparoscopy with biopsy is the only definitive way to diagnose endometriosis. It is an invasive procedure with an overall sensitivity of 97% and a specificity of only 77%. Hallmark findings are the classic powder burn, blue-black lesions.

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Treatment & Management

Prehospital care

Follow established protocols of resuscitation for unstable female patients of reproductive age with acute abdominal/pelvic pain.

Emergency department care

The goal of the emergency physician is to provide pain relief and exclude life-threatening causes of pelvic/abdominal pain. Unstable patients require resuscitation and possibly urgent surgical consult.

Medical management in the ED generally is restricted to pain control. Long-term medical therapy usually is suppressive and rarely curative.

Medical treatments for endometriosis act in a variety of ways to abolish the trophic effect of estradiol on the eutopic and ectopic endometrium. Therefore, the patient develops amenorrhea, because all endometrial tissue becomes inactive.

Although medical treatment can relieve symptoms, the recurrence rate is high after cessation of medications.[6]  All medical treatments are equally effective in managing endometriosis; about 80-85% of patients note improvement in their symptoms. The main difference between medical treatments is their side-effect profile.

Medical treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), progestins (ie, medroxyprogesterone), combination estrogens and progestins, synthetic androgens (ie, danazol), and gonadotropin-releasing hormone analogues with or without hormone replacement therapy. Alternative therapies such as transcutaneous electrical nerve stimulation (TENS) (acupuncture-like TENS, self-applied TENS) may be effective complementary treatments for women with deep endometriosis who have persistent pelvic pain and/or deep dyspareunia despite undergoing hormone therapy.[7]

Urgent acute complications of endometriosis during pregnancy include spontaneous hemoperitoneum and bowel and ovarian complications that often require operative intervention.[3]

Surgical management can be either conservative (ie, laparoscopy with lysis of adhesions) or definitive (ie, total abdominal hysterectomy with bilateral salpingo-oophorectomy [TAH/BSO]).

The fact that TAH/BSO relieves the symptoms of endometriosis is well established. In some cases, however, not all of the endometrial tissue implanted outside the uterus can be removed, and symptoms may persist.

Patients may require surgery involving dissection of the urinary tract, bowel, and/or rectovaginal septum.

There is some degree of recurrence even after surgical therapy.[6]

Stable patients with the presumptive diagnosis of endometriosis require gynecologic referral for long-term management.[8, 9]

Medication

Medication management beyond pain control is outside the scope of emergency medicine. Patients should have their pain controlled and be referred to a gynecologist for further management.

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Contributor Information and Disclosures
Author

Turandot Saul, MD Fellowship Director, Ultrasound Division, Department of Emergency Medicine, St Luke's Roosevelt Hospital

Turandot Saul, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ami K Davé, MD Assistant Professor, Department of Emergency Medicine, New York University School of Medicine

Ami K Davé, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Kyle Hsu, MD, to the development and writing of the source article.

References
  1. Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. Katz VL, ed. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby; 2007. chap 19.

  2. Hummelshoj L, Prentice A, Groothuis P. Update on endometriosis. Women's Health. 2006. 2(1):53-56.

  3. Leone Roberti Maggiore U, Ferrero S, Mangili G, et al. A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Hum Reprod Update. 2016 Jan. 22 (1):70-103. [Medline].

  4. Lee KK, Jharap B, Maser EA, Colombel JF. Impact of concomitant endometriosis on phenotype and natural history of inflammatory bowel disease. Inflamm Bowel Dis. 2016 Jan. 22(1):159-63. [Medline].

  5. Mukund J. Sonography of adnexal masses. Ultrasound Clinics. January 2007. 2:

  6. Busacca M, Chiaffarino F, Candiani M, Vignali M, Bertulessi C, Oggioni G. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol. 2006 Aug. 195(2):426-32. [Medline].

  7. Mira TA, Giraldo PC, Yela DA, Benetti-Pinto CL. Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015 Nov. 194:1-6. [Medline].

  8. Brosens IA. New principles in the management of endometriosis. Acta Obstet Gynecol Scand Suppl. 1994. 159:18-21. [Medline].

  9. Lu PY, Ory SJ. Endometriosis: Current Management. Mayo Clin Proc. 1995. 170:453-463. [Medline].

 
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