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Endometriosis is estimated to occur in 10% to 15% of women of reproductive age in the United States; the highest incidence is in nulliparous white women. It can occur at any age after puberty, although it is most commonly found in women aged 30 to 40. There is a higher incidence of endometriosis in women who marry and bear children later in their lives. The course of the disease is individual and may worsen with each repeated cycle, or the woman may remain asymptomatic throughout her reproductive years. The symptoms and progression of the disease stop after menopause. Ethnicity and race have no known effects on the risk for endometriosis.

^ ASSESSMENT

HISTORY. Elicit a complete history of the woman's menstrual, obstetric, sexual, and contraceptive practices. Endometriosis is difficult to diagnose because some of its symptoms are also manifestations of other pelvic conditions, such as pelvic inflammation, ovarian cysts, and ovarian cancers. A thorough description of the patient's symptoms becomes important, therefore, in the early diagnosis of the condition. Symptoms of endometriosis vary with the location of the ectopic tissue. Some women may even be asymptomatic during the entire course of the disease. The classic triad of symptoms of endometriosis are dysmenorrhea, dyspareunia, and infertility.

The symptoms may also change over time. The major symptom is dysmenorrhea (pain associated with menses) that is different from the normal uterine cramping during the woman's menstrual cycle. This cramping has been referred to as a deep-seated aching, pressing, or grinding in the lower abdomen, vagina, posterior pelvis, and/or back. It usually occurs 1 to 2 days before the onset of the menstrual cycle and lasts 2 to 3 days. Other possible symptoms are pain during a bowel movement around the time of menstruation, a heaviness noted in the pelvic region, menorrhagia, nausea, diarrhea, and pain during sexual intercourse (dyspareunia) or exercise. Some women may have no symptoms at all, and endometriosis is diagnosed during infertility testing.

PHYSICAL EXAMINATION. During a pelvic examination, the cervix may be laterally displaced to the left or right of the midline. Palpation of the abdomen may uncover nodules in the uterosacral ligament, with tenderness in the posterior fornix and restricted movement of the uterus. Palpation may also identify ovarian enlargement that was caused by the presence of ovarian cysts. Speculum examination may reveal bluish nodules on the cervix or posterior wall of the vagina.

320 Endometriosis

During acute flare-ups of the disease, an internal pelvic examination may cause the patient excruciating suprapubic and abdominal pain. The acute disease may be difficult to distinguish from appendicitis or other conditions that lead to an "acute abdomen." The patient may have a rigid abdomen, abdominal guarding, and a low-grade fever.

PSYCHOSOCIAL. Endometriosis is a chronic, long-term condition, with symptoms that occur every month for 2 to 3 days until menopause. Severe discomfort, interferences with activities of daily living or leisure activities, impaired sexual function, and the disappointments of infertility can contribute to depression in women with this chronic disease. Inquire about the level of partner support.

Diagnostic Highlights

General Comments: Endometriosis is often first diagnosed when the woman seeks help for infertility.

Test

Normal Result

Abnormality with Condition

Explanation

Cancer-antigen 125 (CA-125)

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