Endometriosis

Pathophysiology

• Endometriosis is a chronic inflammatory gynaecological condition characterised by hormone-dependent growth of endometrial-like tissue outside the uterus

• Theories include retrograde menstruation, haematogenous spread and genetic predisposition with a significantly increased risk in individuals with a positive family history

• Lesions may be superficial or deep infiltrating, and invasion into the myometrium is referred to as adenomyosis

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History

• Common symptoms include dysmenorrhoea, dyspareunia, dyschezia, dysuria and chronic pelvic pain lasting six months or more

• Gastrointestinal symptoms such as nausea, vomiting, diarrhoea, constipation and bloating may occur alongside premenstrual spotting and heavy menstrual bleeding

• Infertility is a frequent presenting complaint, and severe symptoms unresponsive to NSAIDs or oral contraceptives should prompt further evaluation

• Early symptom onset in adolescence and a first-degree relative with endometriosis markedly increase clinical suspicion

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Examination

• Pelvic examination may reveal cervical fixation, tender adnexal or ovarian masses and fixed pelvic organs

• Abdominal examination can demonstrate lower quadrant tenderness or palpable masses

• A detailed assessment should include evaluation for nodularity in the posterior vaginal fornix suggestive of deep infiltrating disease

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Investigations

• Transvaginal ultrasound can detect endometriomas, although deep infiltrating endometriosis may be missed and normal findings do not exclude the diagnosis

• CA125 levels may be elevated but are non-specific

• Laparoscopy with histological confirmation remains the gold standard, although treatment may begin on a presumed clinical diagnosis

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Management

• Medical Therapy (First-Line)

  • Aim to create a hypoestrogenic state to induce atrophy of ectopic endometrium

  • First-line options include combined oral contraceptive pills (with extended or continuous regimens) or a levonorgestrel-releasing intrauterine device

  • Oral progestogens may be utilised when oestrogen is contraindicated, despite potential adverse effects such as irregular bleeding and breast tenderness

  • GnRH agonists are reserved as second-line due to their side-effect profile and require add-back therapy to mitigate hypoestrogenic effects

• Surgical Management

  • Laparoscopy is the gold standard for both diagnosis and treatment, allowing for excision or ablation of lesions, adhesion lysis and endometrioma removal

  • In severe cases where fertility is not a concern, bilateral salpingo-oophorectomy with or without hysterectomy may be considered

• Multidisciplinary Approach

  • Integrate physiotherapy, pelvic floor therapy, psychological support and specialised pain management into the treatment plan

  • Encourage patients to maintain a symptom diary to monitor cyclical patterns and impact on quality of life

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Referral and Special Considerations

• Refer to a specialist gynaecology service if symptoms persist or worsen after three months of first-line treatment or if deep infiltrating disease is suspected

• Early referral for fertility assessment is advised for individuals over 35 years or those unable to conceive after six months of trying

• Consider additional multidisciplinary input for complex cases, including pain specialists and mental health professionals

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Ongoing Management

• Regular follow-up is essential to monitor treatment response and adjust therapy as needed

• Develop a tailored management plan addressing both physical symptoms and quality of life

• Long-term management may involve combining medical and surgical interventions based on evolving reproductive goals