Endometriosis

doi:10.1136/bmj.39073.736829.BE

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Cynthia Farquhar, postgraduate professor in obstetrics and gynaecology

¹Department of Obstetrics and Gynaecology, National Women's Hospital, University of Auckland, Auckland, New Zealand

c.farquhar{at}auckland.ac.nz

What is endometriosis?

Endometriosis is a chronic condition characterised by growth of endometrial tissue in sites other than the uterine cavity, most commonly in the pelvic cavity, including the ovaries, the uterosacral ligaments, and pouch of Douglas (fig 1).⇓ Common symptoms include dysmenorrhoea, dyspareunia, non-cyclic pelvic pain, and subfertility (table 1).⇓ The clinical presentation is variable, with some women experiencing several severe symptoms and others having no symptoms at all. The prevalence in women without symptoms is 2-50%, depending on the diagnostic criteria used and the populations studied.1 The incidence is 40-60% in women with dysmenorrhoea and 20-30% in women with subfertility.^w1-w3 The severity of symptoms and the probability of diagnosis increase with age.^w4 The most common age of diagnosis is reported as around 40, although this figure came from a study in a cohort of women attending a family planning clinic.^w5 Symptoms and laparoscopic appearance do not always correlate.2 The American Society for Reproductive Medicine has published a classification of severity of endometriosis at laparoscopy.^w6

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Table 1

Common presentations of endometriosis

Fig 1 Mild pelvic endometriosis seen at the time of diagnostic laparoscopy. Arrows show typical endometriotic deposits (reproduced with permission from Dr D A Hill)

Summary points

Medical treatment

Avoid prescribing medical treatment for women who are trying to conceive
The simpler treatments—such as the combined oral contraceptive pill, oral or depot medroxyprogesterone acetate, and the levonorgestrel intrauterine system—are as effective as the gonadotrophin releasing hormone (GnRH) analogues and can be used long term

Surgical treatment

Laparoscopic excision or ablation at time of diagnostic laparoscopy if possible
Endometriomata (large cysts of endometriosis) are best stripped out instead of drainage and ablation

Recurrences

In the five years after surgery or medical treatment 20-50% of women will have a recurrence
Long term medical treatment (with or without surgery) has the potential to reduce recurrence …