Empiric diagnosis and treatment of endometriosis is reasonable, based on clinical suspicion and presentation. Measurement of CA 125 levels may be useful for monitoring disease progress, and MRI has a high sensitivity in detecting endometrial cysts but poor diagnostic accuracy for endometriosis in general. Laboratory tests and radiologic examinations usually are not warranted. Findings of a retroverted uterus, decreased uterine mobility, cervical motion tenderness, and tender uterosacral nodularity are suggestive of endometriosis when present, but these findings often are absent. Pelvic and rectal examinations should be performed, although the yield of the physical examination is low. 15 Nongynecologic causes of pain also should be excluded. The American College of Obstetricians and Gynecologists recommends a pretreatment diagnostic strategy to exclude other causes of pelvic pain such as chronic pelvic inflammatory disease, fibroid tumors, and ovarian cysts. There are no sufficiently sensitive and specific signs and symptoms or diagnostic tests for the clinical diagnosis of endometriosis, and no diagnostic strategy is supported by evidence of effectiveness. A meta-analysis of 22 studies evaluating in vitro fertilization outcomes found that patients with endometriosis had a pregnancy rate of nearly one half that of patients without endometriosis, with decreases in fertilization, implantation, and oocyte production rates. However, tubal distortion is not the only cause of infertility, because patients with endometriosis seem to have poor ovarian reserve with low oocyte and embryo quality. 13 Endometriosis is associated with infertility because of adhesions that distort the pelvic anatomy and cause impaired ovum release and pickup. 12 In a British study of women with pelvic pain, many patients who eventually were diagnosed with endometriosis had been diagnosed previously with irritable bowel syndrome. A patient survey of women in the United Kingdom and United States who were referred to university-based endometriosis centers found that 70 to 71 percent presented with pelvic pain, 71 to 76 percent with dysmenorrhea, 44 percent with dyspareunia, and 15 to 20 percent with infertility. Pelvic pain is the most common presenting symptom other symptoms include back pain, dyspareunia, loin pain, dyschezia (i.e., pain on defecation), and pain with micturition. Symptoms tend to be strongest premenstrually, subsiding after cessation of menses. Laparoscopic cystectomy is preferred over drainage for pain relief in women with endometriosis.Įndometriosis usually becomes apparent in the reproductive years when the lesions are stimulated by ovarian hormones. Presacral neurectomy can be performed in women with midline abdominal pain from endometriosis. Laparoscopic surgery can be performed in women with subfertility and endometriosis. Surgical ablation of endometrial deposits with or without laparoscopic uterine nerve ablation can be performed for pain relief. OCPs, progesterone-only OCPs, and medroxyprogesterone acetate (Provera) should be used as first-line therapies for treating pain associated with endometriosis.īecause gonadotropin-releasing hormone analogues provide equivalent pain relief as OCPs and progestogens with more side effects, they should be used only as second- or third-line agents. The preferred method for diagnosing endometriosis is direct visualization of lesions with histologic confirmation.ĭanazol (Danocrine) may be used for pain relief in patients with endometriosis. Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain from endometriosis at 10 years in 90 percent of patients. Presacral neurectomy is particularly beneficial in women with midline pelvic pain. There is limited evidence that surgical ablation of endometriotic deposits may decrease pain and increase fertility rates in women with endometriosis. Danazol and various gonadotropin-releasing hormone analogues also are effective but may have significant side effects. Oral contraceptive pills, medroxyprogesterone acetate, and intrauterine levonorgestrel are relatively effective for pain relief. Empiric use of nonsteroidal anti-inflammatory drugs or acetaminophen is a reasonable symptomatic treatment, but the effectiveness of these agents has not been well-studied. Such diagnosis requires an experienced surgeon because the varied appearance of the disease allows less-obvious lesions to be overlooked. The preferred method for diagnosis of endometriosis is surgical visual inspection of pelvic organs with histologic confirmation. Serum markers do not provide adequate diagnostic accuracy. Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to be reported.
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