Endometriosis Clinical Presentation

Updated: Jul 26, 2018
  • Author: G Willy Davila, MD; Chief Editor: Michel E Rivlin, MD  more...
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Presentation

History

Common elements in the history include nulliparity and regular menstrual cycles with prolonged flow of 8 or more days. Onset of pain usually precedes flow by a few days and begins to resolve 1-2 days into the menses. Symptoms also usually improve during pregnancy and after menopause; they can recur postpartum or with postmenopausal hormone replacement therapy.

A familial/genetic predisposition has been documented. A woman with a first-degree relative with endometriosis has a lifetime risk of the disease approximately 10 times that of a woman without an affected family member.

When the products of cyclic sloughing of endometriotic implants become entrapped by cyst formation, the resulting mass is referred to as an endometrioma. These can occur in any location but are most commonly found involving one or both ovaries. These masses can become quite painful, and patients with rupture present with an acute surgical abdomen.

Symptoms

Although a significant number of women with endometriosis remain asymptomatic (approximately one third), [1] the most important point to remember is that the degree of visible endometriosis has no correlation with the degree of pain or other symptomatic impairment, because the location and depth of endometrial implants affect the symptomatology. [39] However, pain does correlate with the depth of tissue infiltration, as pain is thought to be related to the degree of peritoneal inflammation rather than the volume of implants. [40, 41] Associated intrapelvic/intra-abdominal adhesions are also important determinants of the degree of pain experienced. Midline disease is generally believed to be more painful than lateral disease. In addition to pain, patients present with nonspecific symptoms of fatigue, generalized malaise, and sleep disturbances.

Symptoms of endometriosis can be variable but typically reflect the area of involvement. Such symptoms may include the following:

  • Dysmenorrhea

  • Heavy or irregular bleeding

  • Pelvic pain

  • Lower abdominal or back pain [2]

  • Dyspareunia

  • Dyschezia (pain on defecation) often with cycles of diarrhea and constipation

  • Bloating, nausea, and vomiting

  • Inguinal pain

  • Pain on micturition and/or urinary frequency

  • Pain during exercise

Because most endometriotic implants are found on the uterus, ovaries, and posterior peritoneum, the patient usually presents with a history of progressively increasing pelvic pain and/or secondary dysmenorrhea. Not uncommonly, women report painful bowel movements, diarrhea, or even hematochezia in association with their menses when endometriosis involves the rectosigmoid colon. Likewise, dysuria, flank pain, or hematuria may be present if the bladder or ureters are involved.

Cyclic pain is pain that accompanies bleeding at the time of menstruation. This could involve the bladder (hematuria), bowel (hematochezia and painful defecation), or, rarely, bleeding at uncommon sites such as the umbilicus, abdominal wall, or perineum. Occasionally, patients present with a cyclically painful expanding mass in a pelvic surgery scar; excision reveals a focus of endometriosis. In one large case series, the average onset of cyclic or noncyclic pain was 2.9 years after menarche.

Acute exacerbations are believed to be caused by chemical peritonitis due to leakage of old blood from an endometriotic cyst. With conscious laparoscopic pain mapping, painful lesions were found to involve peripheral spinal nerves rather than autonomic nerves. [39]

Secondary dysmenorrhea occurs twice as often in women with endometriosis as in controls. [33] Pain frequently commences before menses. Endometriosis should be considered in a patient presenting with significant dysmenorrhea, and the patient should be started on empiric therapy.

Patients who are sexually active may report deep dyspareunia that is worst in the premenstrual phase of the cycle. Deep dyspareunia may be due to scarring of the uterosacral ligaments, nodularity of the rectovaginal septum, cul-de-sac obliteration, and/or uterine retroversion, all of which may also lead to chronic backache. These symptoms are exaggerated during menses. Women with deep infiltration of the uterosacral ligaments were shown to have the most severe impairment of sexual function. [42]

More uncommon cyclic symptoms include hemoptysis (pulmonary involvement), catamenial seizures (endometriotic lesions in the brain), and umbilical bleeding (implants in the umbilicus).

Partial or complete bowel obstruction occasionally occurs because of either adhesion formation or a circumferential endometriosis lesion. Ureteral obstruction and hydronephrosis can result from endometrial implants on the ureter or mass effect from an endometrioma.

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Physical Examination

Patients with endometriosis do not frequently have any physical findings beyond tenderness related to the site of involvement. [3, 4, 5] The most common finding is nonspecific pelvic tenderness. In one study, 22% of adolescents had abnormal physical findings consistent with anatomic lesions found during surgery.

On pelvic evaluation, tenderness upon examination is best detected at the time of menses. The hallmark finding on examination is the presence of tender nodular masses along thickened uterosacral ligaments, the posterior uterus, or the posterior cul-de-sac. Obliteration of the cul-de-sac in conjunction with fixed uterine retroversion implies extensive disease. Occasionally, a bluish nodule may be seen in the vagina due to infiltration from the posterior vaginal wall.

Rupture of an ovarian endometrioma may present as an acute abdomen.

Extensive involvement of the rectum and other areas of the gastrointestinal (GI) tract may cause adhesions and obstruction.

Examination should also include evaluation for cervicitis, abnormal discharge, and sexually transmitted diseases (STDs).

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Staging

The American Society for Reproductive Medicine classification of endometriosis is currently the most widely used staging system. [43] Point scores are assigned based on the number of lesions and their bilaterality as well as associated adhesion formation noted at the time of surgery. Lesion size is also a scoring factor. This classification is a fairly accurate method of recording laparoscopic findings. However, high intraobserver and interobserver variability precludes its use in comparing the outcomes of therapeutic studies. [44] Furthermore, this staging system does not correlate well with pain and dyspareunia, [45] and fecundity rates cannot be predicted accurately.

However, the patient's stage (ie, 1-4, or minimal, mild, moderate, and severe) may be useful in determining her prognosis for subsequent reproduction. The staging system can also be used to monitor a patient's response to therapeutic efforts. Surgical exploration is required for this staging system, both initially and for subsequent follow-up; a discussion of its details is beyond the scope of this article.

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