- Signs of minimal or mild endometriosis include tenderness or nodularity in the posterior cul-de-sac, especially at the uterosacral ligaments, and anterior cul-de-sac nodularity.
- Endometriosis can be associated with infertility at all stages of disease.
- Indications for laparoscopy include infertility of more than 1 year without other symptoms or after 6 months if the patient has other symptoms or is more than 35 years of age. Patients with pelvic pain that has not responded after 3 months of nonsteroidal anti-inflammatory drugs and/or oral contraceptives also are candidates.
- Following adequate surgical extirpation of disease, no further postoperative medical treatment is necessary for patients with either pain or infertility. However, oral contraceptives have benefits for many patients who are not attempting to conceive.
This case represents 1 of the challenges of treating minimal to mild endometriosis—disease without adhesions, invasive lesions, or endometriomas. Endometriosis is suggested in this patient by tenderness or nodularity in the posterior cul-de-sac, especially at the uterosacral ligaments, and anterior cul-de-sac nodularity. The patient’s complaint of pain does not necessarily indicate severe disease. Rather, the relationship between minimal or mild disease and symptoms is unclear. The patient may report significant pain when only superficial implants and minimal adhesions are present.
Although hysterectomy is the definitive treatment for patients with recurrent or intractable pain associated with endometriosis, I make every effort to avoid this operation in young women with minimal to mild disease. This article describes 4 other options—no treatment, ovarian suppression, surgical treatment, and combined treatment—and points out potential pitfalls associated with each approach.
Clinical presentation. Endometriosis presents as pelvic pain in about 50% of patients, infertility in about 25%, pain and infertility in about 25%, and as ovarian endometrioma in less than 5% of cases.1-3 Asymptomatic disease is frequent: from 1% to 40%.1-3 The disease may occur any time after puberty, including adolescence. For other symptoms and characteristics, see “Endometriosis: A snapshot”.
Physical examination. Pelvic examination should be performed at the time of menses, when disease is more easily identified. The location of tenderness often corresponds to the location of the pain. As in the example case, signs of minimal or mild disease include:
- tenderness or nodularity in the posterior culde-sac, especially at the uterosacral ligaments
- anterior cul-de-sac nodularity
Indications for laparoscopy include infertility of more than 1 year without other symptoms or after 6 months if the patient has other symptoms or is more than 35 years of age. Evaluation for other female factors and sperm quality should be conducted prior to laparoscopy. Patients with pelvic pain that has not responded after 3 months of NSAIDs and/or oral contraceptives (OCs) also are candidates for laparoscopy. In the case described above, I would recommend at least a 3-month trial of OCs and NSAIDs before performing laparoscopy.
Staging the disease. The American Society for Reproductive Medicine has developed a staging system with scores from 1 to 150. Minimal and mild disease ranges from 1 to 15.4
Management options. Depending on the woman’s reproductive goals, 1 of the 4 options discussed below may be recommended.
Prevalence. Endometriosis affects about 7% of reproductive-aged women—approximately 5 million Americans. Most of these women are unaware that they have the disease, although many may suffer symptoms ranging from pelvic pain to infertility.
Symptoms. Endometriosis is suggested by a variety of symptoms, including dysmenorrhea, dyspareunia (especially with aching following coitus, as in the case described at the opening of this article), dyschezia, dysuria, mittelschmerz, or focal or generalized pelvic pain. Hematuria and hematochezia also may be present. About 30% of patients with endometriosis have no pain.1
Diagnostic challenges. Deeply invasive endometriosis that is overlooked or develops outside the posterior cul-de-sac can be inappropriately staged as minimal or mild disease.
Causes of pain. Pain symptoms often do not correlate well with disease severity. Pain may be due to secretion of irritating factors (eg, histamine), adhesions that cause scarring or retraction, immunologic reactivity, or other unknown entities.
Infertility can occur at any stage. Not surprisingly, patients who have severe or extensive disease have a poorer prognosis than those with minimal or mild disease.
Endometriosis is a progressive disease, but the rate of progression and nature of lesions vary from patient to patient. Adhesions develop due to the inflammatory process caused by longstanding endometriosis, becoming more extensive and dense over time. Complete cul-de-sac obliteration can result from longstanding invasive and adhesive disease or may stem from abnormal mullerian development.