Endometriosis is the abnormal development of endometrial glands and stoma outside of the uterus. It is associated with dysmenorrhea, dyspareunia, and infertility. The American Society of Reproductive Medicine (ASRM) developed a revised staging scheme in order to standardize communication between physicians regarding their patients, between investigators for research protocols and to follow effects of therapy (27).
The mechanism of action whereby endometriosis causes infertility is complex. Severe endometriosis with adhesions and adherent pelvic organs results in mechanical infertility. It is difficult to identify the mechanism whereby inimal and moderate endometriosis causes infertility. Increased peritoneal fluid, increase peritoneal prostaglandin concentration, and interference with normal ovarian folliculogenesis have all been postulated as possible mechanism (28). However, no direct evidence documents that between mild and minimal endometriosis causes infertility (29). Indeed, some have postulated endometriosis is a result rather than a cause of infertility.
Patients with endometriosis experience a spectrum of symptoms ranging from incapacitating dysmenorrhea and severe dyspareunia to none at all. Although 30% of infertile patients have endometriosis (30), it is unknown how many patients who have endometriosis are infertile. Classically, patients have dysmenorrhea which begins during the menses and over time extends to the prior luteal phase.
Cyclical hemoptysis and hematochezia may occur in patients with endometriosis implants in the lung; however, very few of patients with endometriosis have these remote implants.
Endometriosis may be occasionally palpated on pelvic exam if there are implants on the uterosacral ligaments or on the posterior surface of the uterus; however, physical examination is usually not helpful in the diagnosis of endometriosis.
Endometriosis is diagnosed by visual inspection. Endometrial implants over the pelvic organs may be biopsied for histological confirmation. Endometrial glands and stroma are seen microscopically. The American Society of Reproductive Medicine recommends using a standard staging system to document the severity of each patient's disease. The system incorporates superficial and deep lesions, adhesions, and the location and size of each lesion. Standardized staging allows communication between physicians and evaluation of treatment efficacy.
Endometriosis causing pain may be treated with surgical or medical therapy. Surgical extirpation of lesions and adhesions is successful in alleviating pain for endometriosis but is less effective in increasing fertility caused by endometriosis (31). Preventing menstruation with the use of continuous oral contraceptive or continuous progestin therapy may also relieve pain. Medical menopause induced by GnRH analogues has also been effective in reducing the implants of endometriosis. However, once normal cycles and hormones resume, the implants return. Medical therapy does not have much effect on the adhesions associated with endometriosis (32,33). Similarly, endometriomas of the ovary are decreased in size by medical therapy but are rarely completely treated. In vitro fertilization is more effective than either surgery or medicine in increasing fertility in patients with endometriosis (28).