O&G · Gynaecological health — chronic pelvic pain and endometriosis
Endometriosis: symptom profile, diagnosis and medical management (ESHRE 2022)
Also known as Endometriosis · Endometrioma · Chocolate cyst · Deep infiltrating endometriosis · DIE · Cyclical pelvic pain syndrome
Exam-exhaustive FRANZCOG fellowship topic on endometriosis: the symptom profile (secondary dysmenorrhoea, deep dyspareunia, cyclical bowel and bladder symptoms, chronic pelvic pain), the diagnostic delay of about 7 years and the paradigm shift from laparoscopy-first to clinical-plus-imaging-first diagnosis, the medical management ladder from simple analgesia through continuous COCP/LNG-IUS and progestins (dienogest) to GnRH analogues with add-back, the fertility preservation discussion, and endometrioma classification (rASRM, EFI). Surgical management has its own companion topic. RANZCOG-primary (Australian Living Evidence), globally tagged to ESHRE 2022, MRCOG, ABOG, FRCSC and MRCPI.
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Cyclical dyschezia, cyclic dysuria or cyclic rectal/urinary bleeding in any reproductive-age woman — deep infiltrating endometriosis involving bowel or bladder; do not dismiss as IBS
- Progressive, secondary dysmenorrhoea with deep dyspareunia unresponsive to NSAIDs and the COCP — suspect endometriosis; the diagnostic delay is the enemy
- Adnexal mass with ground-glass echogenic content on TVUS plus dysmenorrhoea — ovarian endometrioma; an endometrioma in a postmenopausal woman is malignancy until proven otherwise
- Cyclical haematuria or flank pain with hydronephrosis — ureteric or bladder DIE with silent obstructive uropathy risk
- Sudden severe lower abdominal pain with a known endometrioma — possible rupture or torsion; emergency surgical assessment
- Cyclical haemoptysis or catamenial pneumothorax — thoracic endometriosis; rare but classic
A 27-year-old has spent six years being told her periods are "just bad". She now has deep dyspareunia that is ending her relationship, cyclical pain on opening her bowels, and fatigue that is costing her work. She has endometriosis — and the six-year wait is the disease, not the diagnosis. Your job is to recognise the syndrome on the pattern, image it, and start treatment the same month, not the same decade. ESHRE 2022 and the Australian Living Evidence guideline have moved the field precisely here: clinical diagnosis plus imaging is enough to treat.[1][3]
Overview and definition
Endometriosis is the presence of functional endometrial glands and stroma outside the uterine cavity, producing a chronic, oestrogen-dependent, inflammatory disease. It affects roughly 1 in 10 women of reproductive age — about 10% — and is one of the commonest causes of life-impacting pelvic pain and infertility.[2][4]
The burden — the numbers that frame every consultation
The disease has three phenotypes, and the phenotype drives both the symptoms and the management:[2]
- Superficial peritoneal endometriosis — peritoneal implants on the pelvic peritoneum, uterosacral ligaments, bladder peritoneum; the commonest form, often the source of pain.
- Ovarian endometrioma ("chocolate cyst") — an endometriotic cyst within the ovary containing old dark blood; the classical TVUS finding.
- Deep infiltrating endometriosis (DIE) — fibrotic nodules invading more than 5 mm beneath the peritoneum, into the rectovaginal septum, bowel wall, bladder, or ureter; the source of cyclical bowel/bladder symptoms and the most surgically complex disease.[2]
References12ShowHide
- [1]Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Hum Reprod Open, 2022.PMID 35350465
- [2]Zondervan KT, Becker CM, Missmer SA Endometriosis. N Engl J Med, 2020.PMID 32212520
- [3]Nnoaham KE, Hummelshoj L, Webster P, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril, 2011.PMID 21718982
- [4]Nisenblat V, Bossuyt PM, Farquhar C, et al. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev, 2016.PMID 26919512
- [5]Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod, 2014.PMID 24435778
- [6]Strowitzki T, Marr J, Gerlinger C, et al. Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis. Hum Reprod, 2010.PMID 20089522
- [7]Petraglia F, Hornung D, Seitz C, et al. Reduced pelvic pain in women with endometriosis: efficacy of long-term dienogest treatment. Arch Gynecol Obstet, 2012.PMID 21681516
- [8]Hudelist G, Valentin L, Saridogan E, et al. What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis. Facts Views Vis Obgyn, 2021.PMID 35026095
- [9]Adamson GD Endometriosis Fertility Index: is it better than the present staging systems? Curr Opin Obstet Gynecol, 2013.PMID 23571831
- [10]Maheux-Lacroix S, Nesbitt-Hawes E, Deans R, et al. Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis. Hum Reprod, 2017.PMID 29040471
- [11]Benagiano G, Guo SW, Puttemans P, et al. Progress in the diagnosis and management of adolescent endometriosis: an opinion. Reprod Biomed Online, 2018.PMID 29174167
- [12]Tuttlies F, Keckstein J, Ulrich U, et al. ENZIAN-score, a classification of deep infiltrating endometriosis. Zentralbl Gynakol, 2005.PMID 16195969