Treatment Guideline Chart

Endometriosis is an estrogen-dependent growth of extrauterine endometrial-like tissue that induces a chronic inflammatory response.

Main clinical features include chronic pelvic pain, dyspareunia and infertility.

Patients with endometriosis may also be completely asymptomatic.

Goals of treatment are decreasing pain, enhancing fertility, and preventing progression or recurrence. 


Endometriosis Signs and Symptoms


  • An estrogen-dependent growth of endometrial-like tissue found outside the uterus inducing a chronic inflammatory response
    • Pelvic organs (especially ovaries) and peritoneum are frequently affected
  • 5-10% of reproductive-aged women are affected
  • Prevalence is higher in Asian women while a lower incidence is found among African women as compared to Caucasians 

Risk Factors

  • Genetics, particularly among the patient’s 1st-degree relatives
  • Prolonged exposure to endogenous estrogen (early menarche or late menopause)
  • Short menstrual cycle
  • Low body mass index (BMI)
  • Obstruction of menstrual flow (eg müllerian anomalies)
  • High consumption of red meat and trans fat


  • Pathogenesis of endometriosis remains unclear but theories include:
    • Retrograde menstruation (Sampson’s theory)
    • Immune system problems  
    • Metaplastic changes of the peritoneal coelomic mesothelial cells
    • Spread of ectopic menstrual tissue via the bloodstream or lymphatic system
    • Differentiation of cells from bone marrow into ectopic endometrial tissue
    • Increase in estrogen sensitivity with increase in progesterone resistance

Signs and Symptoms

  • Main clinical features include:
    • Chronic pelvic pain (found in 70-82% of patients)
    • Dyspareunia (suggests deep posterior infiltration)
    • Infertility (21% prevalence rate)
  • Other symptoms may include severe dysmenorrhea, pain on ovulation, noncyclical pelvic pain, cyclical bowel or bladder symptoms with or without abnormal bleeding or pain, dyschezia, dysuria, chronic fatigue, or abdominal or lower back discomfort
    • In adolescents, endometriosis is the most common cause of secondary dysmenorrhea
  • Although it is vital to consider the patient’s complaints affecting physical, mental and social well-being, it should be noted that patients with endometriosis may be completely asymptomatic (with 2-22% prevalence rate)

Types of Endometriosis

  • Types of endometriosis include: 
    • Adenomyosis (asymmetrical uterine enlargement)
    • Ovarian endometriomas or chocolate cysts
    • Superficial peritoneal endometriosis
    • Deep infiltrating endometriosis (lesions that penetrate >5 mm to the peritoneum)
    • Disseminated endometriosis
  • Complications of endometriosis include pain, fertility problems, and risk of developing ovarian cancer 
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