Basics
Description
- Presence of endometrial tissue and glands outside uterus
- An estrogen-dependent chronic inflammatory disease
- Affects 6-10% of women of reproductive age and 50-60% of women/teenage girls with pelvic pain
- Endometrial tissue found anywhere in pelvic cavity, on ovaries, uterine ligament (due to retrograde menstruation) and distant sites, including bowel and lungs
Etiology
Not prior to menarche
Risk Factors
- Anatomic obstruction of menstrual outflow
- Early menarche
- Short menstrual cycles
- Genetic component suggested by twin and family studies
Diagnosis
Signs and Symptoms
History
- Dysmenorrhea (50-90%)
- Deep pelvic pain
- Dyspareunia
- Dysfunctional uterine bleeding
- Lower abdominal pain
- Nausea, abdominal distention
- Infertility (30-50%)
Physical Exam
- Focal pain or tenderness on pelvic exam
- Tenderness along uterosacral ligament
- Retroverted uterus
- Rectovaginal nodularity
- Pelvic mass
- Physical exam can vary depending on location of endometrial tissue
- Catamenial pneumothorax occurs during menses due to pleural endometriosis
Essential Workup
- Pregnancy test
- GC/chlamydia testing
- Other tests as directed by history and physical exam
- Rarely diagnosed in ED
Diagnosis Tests & Interpretation
Lab
- Pregnancy test
- GC/chlamydia testing
- Hematocrit if bleeding
- Type and screen if significant bleeding
- Other labs as directed by history and physical exam
Imaging
- Ultrasound (11% sensitivity)
- Doppler ultrasound
- CT scan (15% sensitivity)
- MRI (69% sensitivity; 75% specificity)
- Typically not helpful in ED
Diagnostic Procedures/Surgery
Laparoscopy usually required for definitive diagnosis
Differential Diagnosis
- Appendicitis
- Dysfunctional uterine bleeding
- Ectopic pregnancy
- Inflammatory bowel disease
- Irritable bowel disease
- Menstrual cramps/mittelschmerz
- Ovarian cyst
- Ovarian torsion
- Pelvic inflammatory disease
- Tubo-ovarian abscess
Treatment
Pre-Hospital
- Stabilize as needed.
- Pain control as necessary
Initial Stabilization/Therapy
- Treat hypotension or tachycardia from blood loss with isotonic IV fluids
- May need to transfuse packed red blood cells (PRBCs) if significant bleeding
Ed Treatment/Procedures
- Analgesia
- Oral contraceptive (i.e., medroxyprogesterone acetate) or gonadotropin-releasing hormone agonist (i.e., leuprolide acetate) in consultation with gynecologist or primary care physician
- Gynecology consultation for significant bleeding, pain, or serious complication
Medication
- Ibuprofen: 400-800 mg PO q6-8h (max. 3.2 g/d)
- Acetaminophen: 325-650 mg PO q4-6h (max. 4 g/d)
- Ketorolac: 15-30 mg IV or 30-60 mg IM
- Morphine: 4-8 mg IM/IV or equivalent analgesic
First Line
- Ibuprofen: 400-800 mg PO q6-8h (max. 3.2 g/d)
- Acetaminophen: 325-650 mg PO q4-6h (max. 4 g/d)
- Ketorolac: 15-30 mg IV or 30-60 mg IM
Follow-Up
Disposition
Admission Criteria
- Intractable pain
- Significant bleeding
- Unclear diagnosis
- Need for further workup and treatment
- Peritoneal signs
Discharge Criteria
Most patients with suspected endometriosis can be discharged with pain control and gynecology referral
Followup Recommendations
Suspected cases of endometriosis should be referred to a gynecologist for evaluation and treatment
Pearls and Pitfalls
- Occurs in 6-10% of women of reproductive age
- Endometriosis frequently causes cyclical pelvic pain
- Rarely diagnosed initially in ED; delay between symptom onset and diagnosis frequently years
- Rule out other emergency medical conditions and treat symptoms as needed
- Endometriosis is a chronic condition that necessitates outpatient monitoring by a gynecologist or primary care physician
Additional Reading
- Cirilli AR, Cipot SJ. Emergency evaluation and management of vaginal bleeding in the nonpregnant patient. Emerg Med Clin North Am. 2012;30:991-1006.
- Giudice LC. Clinical practice. Endometriosis. N Eng J Med. 2010;362:2389-2398.
- McLeod BS, Retzloff MG. Epidemiology of endometriosis: An assessment of risk factors. Clin Obstet Gynecol. 2010;53:389-396.
- Vercellini P, Crosignani P, Somigliana E, et al. "Waiting for Godot": A commonsense approach to the medical treatment of endometriosis. Hum Reprod. 2011;26:3-13.
Codes
ICD9
- 617.1 Endometriosis of ovary
- 617.3 Endometriosis of pelvic peritoneum
- 617.9 Endometriosis, site unspecified
- 617.0 Endometriosis of uterus
- 617.2 Endometriosis of fallopian tube
- 617.4 Endometriosis of rectovaginal septum and vagina
- 617.5 Endometriosis of intestine
- 617.6 Endometriosis in scar of skin
- 617.8 Endometriosis of other specified sites
- 617 Endometriosis
ICD10
- N80.1 Endometriosis of ovary
- N80.3 Endometriosis of pelvic peritoneum
- N80.9 Endometriosis, unspecified
- N80.0 Endometriosis of uterus
- N80.2 Endometriosis of fallopian tube
- N80.4 Endometriosis of rectovaginal septum and vagina
- N80.5 Endometriosis of intestine
- N80.6 Endometriosis in cutaneous scar
- N80.8 Other endometriosis
- N80 Endometriosis
SNOMED
- 129103003 Endometriosis (disorder)
- 198251001 Endometriosis of pelvic peritoneum
- 266589005 Endometriosis of ovary
- 76376003 endometriosis of uterus (disorder)
- 22611009 Endometriosis of fallopian tube
- 5562006 Endometriosis of intestine
- 57493005 Endometriosis of vagina (disorder)