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Endometriosis, Emergency Medicine

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)