Management of Endometriosis
Endometriosis represents a significant health problem for women of reproductive age. The etiology, the relationshipbetween the extent of disease and the degree of symptoms, the effect on fertility, and the most appropriate treatmentof endometriosis remain incomplete. The purpose of this document is to present the evidence, including risks and benefits, for the effectiveness of medical and surgical therapy for adult women who are symptomatic with pelvic pain orinfertility or both. Treatment options for adolescents are discussed in other documents .
BackgroundIncidence
Endometriosis is a gynecologic condition that occursin 6–10% of women of reproductive age , with aprevalence of 38% (range, 20–50%) in infertile women, and in 71–87% of women with chronic pelvic pain. Contrary to much speculation, there are no data tosupport the view that the incidence of endometriosis isincreasing , although improved recognition of endometriotic lesions may have led to an increase in the rateof detection . There also appears to be no particularracial predisposition to endometriosis.
A familial association of endometriosis has beensuggested, and patients with an affected firstdegree relative have nearly a 7–10fold increased risk of developingendometriosis. There is a strong concordance inmonozygotic twins . The proposed inheritance is characteristic of a polygenicmultifactorial mechanism. A number of genetic polymorphisms have been identified .
Etiology
Endometriosis is a chronic gynecologic disorder whoseprincipal manifestations are chronic pain and infertility. The pathogenesis of endometriosis is complex but is stillthought to be principally associated with attachment andimplantation of endometrial glands and stroma on theperitoneum from retrograde menstruation. Other theories such as hematogenous or lymphatic transport, stemcells from bone marrow, and coelomic metaplasia mayexplain some clinical circumstances .The complex interaction between aberrant expression of endometrial genes as well as altered hormonalresponse will predispose patients to the developmentof endometrial lesions. Key components in thedevelopment of endometriosis are local overproductionof prostaglandins by an increase in cyclooxygenase2(COX2) activity and overproduction of local estrogenby increased aromatase activity. Progesterone resistancedampens the antiestrogenic effect of progesterone andamplifies the local estrogenic effect.
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