Summary

Endometriosis is a chronic, oestrogen-dependent condition characterised by the presence of endometrial-like tissue (glands and stroma) outside the uterus. Common sites include the ovaries (Endometrioma – "Chocolate Cyst"), Pouch of Douglas, Uterosacral ligaments, Bowel, and Bladder. The ectopic tissue undergoes cyclical bleeding, causing chronic inflammation, fibrosis, and adhesions. Classic symptoms include Cyclical pelvic pain, Dysmenorrhoea (Painful periods), Deep dyspareunia (Pain deep during sex), and Infertility. Diagnosis is often delayed; the Gold Standard is Laparoscopy with histological confirmation. Management options include Analgesia, Hormonal suppression (COCP, Mirena IUS, GnRH analogues), and Surgical excision/ablation. Severe disease (Deep Infiltrating Endometriosis – DIE) involving bowel or bladder requires specialist MDT management. ESHRE 2022 guidelines provide evidence-based guidance.

Key Facts

• Definition: Endometrial-like tissue outside the uterus.
• Incidence: ~10% of reproductive-age women.
• Sites: Ovaries (Endometrioma), Pouch of Douglas, Uterosacral ligaments, Bowel, Bladder.
• Classic Symptoms: Cyclical Pelvic Pain, Dysmenorrhoea, Deep Dyspareunia, Infertility.
• Gold Standard Diagnosis: Laparoscopy + Biopsy.
• Treatment: Hormonal (COCP, Mirena, GnRH Analogues). Surgical Excision.

Clinical Pearls

"The 4 Ds": Dysmenorrhoea, Deep Dyspareunia, Dyschezia (Painful defecation), Difficulty conceiving (Infertility).

"Chocolate Cyst = Endometrioma": Dark, old blood within an ovarian cyst from cyclical bleeding.

"Diagnostic Delay Averages 7-10 Years": Endometriosis is often normalised or misdiagnosed.

"GnRH Analogues = Chemical Menopause": Effective but side effects limit long-term use.

Why This Matters Clinically

Endometriosis is common and debilitating. It significantly impacts quality of life and fertility. Early recognition reduces diagnostic delay.

Theories

Oestrogen Dependence

• Endometriotic tissue expresses oestrogen receptors.
• Local oestrogen production (Aromatase).
• Regresses after menopause.

Note: rASRM score does NOT correlate well with symptoms or pain.

Endometriosis and Adenomyosis often coexist.

Key Guidelines

Scenario 1:

• Stem: A 28-year-old woman presents with severe dysmenorrhoea, deep dyspareunia, and 2 years of trying to conceive. Pelvic USS shows a 5cm "ground glass" cyst on the left ovary. What is the likely diagnosis?
• Answer: Endometriosis with Endometrioma ("Chocolate Cyst").

Scenario 2:

• Stem: What is the Gold Standard investigation for definitive diagnosis of endometriosis?
• Answer: Laparoscopy with Histological Biopsy.

Scenario 3:

• Stem: A patient with endometriosis wishes to avoid surgery. What hormonal treatments can suppress the disease?
• Answer: COCP (Continuous), Progestogens, Mirena IUS, GnRH Agonists ("Chemical Menopause").

What is Endometriosis?

Endometriosis is a condition where tissue similar to the lining of the womb grows in other places, such as the ovaries, pelvis, or bowel. This tissue responds to hormones and causes pain and inflammation.

What are the symptoms?

• Very painful periods.
• Pain during or after sex.
• Difficulty getting pregnant.
• Pain when going to the toilet during your period.

How is it treated?

• Painkillers.
• Hormonal treatments: Pill, Coil (Mirena), Injections.
• Surgery: Keyhole surgery to remove the tissue.

Key Counselling Points

1. It's Not In Your Head: "Endometriosis is a real medical condition."
2. Chronic Condition: "There is no cure, but symptoms can be managed."
3. Fertility: "Many women with endometriosis can still conceive, with or without help."

• Sampson (1927): Proposed retrograde menstruation theory.
• Laparoscopic Era (1970s-80s): Enabled diagnosis and surgical treatment.
• GnRH Agonists (1980s): Introduced for medical management.
• Recent Advances: GnRH antagonists (Oral), Endometriosis centres, Research into biomarkers.