Symptoms commonly associated with endometriosis include perimenstrual lower abdominal pain and dyspareunia.2
However, patients with endometriosis can also present with dysuria, hematuria, urinary frequency, and painful voiding, particularly if the bladder is involved.2,21
Patients with endometriosis may have no symptoms at all, and the pain typically ascribed to endometriosis often has little correlation with the location or extent of the disease.2,22
Therefore, the clinician should consider other causes of pain, even if endometriosis is diagnosed.
Endometriosis is defined as the presence and growth of endometrial mucosa, glands, and stroma outside of the uterus.2
Common sites of implantation include the ovaries, uterosacral ligaments, cul-de-sac, and the uterovesical peritoneum.21,22
As with the normal uterine endometrium, these extrauterine implants remain under the cyclic influence of ovarian hormones, and are stimulated to grow and then break down with each menstrual cycle.22
Pain is caused by inflammation that results from cyclic sloughing of these endometrial glands, by the release of neurokinins, and by pressure and traction on surrounding tissue from adhesions, if they are present.
Endometriosis is suspected based on the patient's history and physical examination, and confirmed by histologic findings from laparoscopic-guided biopsy. It is essential to ask about symptoms like dyspareunia and urinary urgency/frequency. During the physical examination, the physician may detect tender nodules and masses in the pelvic region, a tender retroverted uterus, or implants in uterosacral ligaments. Visualization of lesions by laparoscopy, with confirmation by biopsy, is considered the “gold standard” for diagnosis.2
Evidence increasingly suggests that biopsy is required to confirm the diagnosis of endometriosis.22
In a study by Walter et al23
that investigated the accuracy of laparoscopic visualization alone in making a diagnosis, only 49% (67/138) of sites that appeared visually positive for endometriosis had positive histology on biopsy. Findings responsible for the false-positives included endosalpingiosis, malignancies, carbon deposits from previous ablations, and other abnormalities, as well as normal peritoneum.23
Optimal approaches to the management of endometriosis are determined by many factors, including either or both the patient's desire for fertility augmentation and pain relief, the patient's age, and the stage of disease. The approach can be pharmacologic, surgical, or a combination of both. Analgesic therapy with nonsteroidal antiinflammatory agents is appropriate for the patient with mild, premenstrual endometriosis-related pain.22,24
The goals of hormone therapy are to interrupt the growth of endome-trial tissue implants by suppressing estrogen production or to promote the atrophy of such implants through progestational agents, or both of these. Combined estrogenprogestin oral contraceptives (OCs) are generally considered first-line hormone therapy. Low-dose, continuous, monophasic OC regimens (versus intermittent OC regimens) appear to be effective for suppressing endometrial growth. Other therapies that may be used include progestational agents like medroxyprogesterone acetate and norethindrone acetate, the weak androgen danazol, and gonadotropin-releasing (GnRH) agonists like leuprolide, nafarelin, or goserelin.22,24
It is important to note that suppressive hormone therapies, such as GnRH agonists and OCs, also may have beneficial effects for patients with IC, irritable bowel syndrome, and almost any pain disorder that is associated with perimenstrual symptom flares.25,26
Therefore, pain relief on suppressive hormone therapy does not necessarily equate with a diagnosis of endometriosis, or even the presence of a gynecologic disorder.
Pharmacologic therapy often succeeds in suppressing pain symptoms and halting the progression of endometriosis. However, once treatment is discontinued, endometriosis will commonly become active again. For women with moderate or severe endometriosis whose symptoms are unrelieved by pharmacologic treatment, or for women who are older, surgery may be the most appropriate therapy. Conservative surgery attempts to eradicate visual signs of endometriosis and adhesions, eliminate symptoms of CPP, and restore the pelvic anatomy to a normal condition.22
However, because surgery cannot eliminate all microscopic endometrial implants, the disease may progress and symptoms may recur. For women with severe persistent endometriosis, the only treatment option may be a hysterectomy with bilateral salpingo-oophorectomy.