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  • image Endometriosis should be suspected in any woman of reproductive age with recurring cyclic or acyclic pelvic pain and/or subfertility, especially if pain does not improve with nonsteroidal anti-inflammatory drugs and hormonal contraceptives.

  • image The etiology of endometriosis is likely multifactorial and requires a genetic or immunologic predisposition. Retrograde menstruation is the most widely accepted theory to account for displacement of endometrial tissue, although alternative theories have been proposed.

  • image Treatment goals include improvement of painful symptoms and maintenance or improvement of fertility. Therapy is considered successful based on resolution of symptoms or achievement of pregnancy.

  • image Both drug therapy and surgery may treat endometriosis-related pain, but infertility can be treated only with surgery or assisted reproductive techniques.

  • image No medical therapy has been proven to be more effective than another; thus, the choice among agents is determined primarily by side-effect profile, cost, and individual patient response.

  • image For endometriosis pain, surgical therapy is typically reserved for medical therapy failure.

  • image Diagnosis of endometriosis can be made only via surgical visualization of lesions, not by physical examination or laboratory testing. Empiric treatment without confirmation of diagnosis is acceptable in most cases.

  • image To help avoid loss of bone mineral density, add-back therapy should be used in any woman receiving a gonadotropin-releasing hormone agonist.

image Endometriosis causes secondary dysmenorrhea and is associated with infertility. Presence of endometrial tissue outside the uterus is chronic and relapsing. Endometriosis treatment targets pain relief and fertility improvement.


Endometriosis has up to a 10% estimated prevalence in the general female population.1,2,3 Though the prevalence is substantially higher in patients with pelvic pain or infertility. Only 4% of premenopausal women presenting to primary care for nongynecologic problems have endometriosis, whereas up to 80% of adult women and 50% of adolescents with chronic pelvic pain are diagnosed with the disorder.3,4 The incidence is 10-fold higher in women with infertility (20%-50%) compared with that in fertile women (0.5%-5%).1,2,3,4,5 A genetic predisposition for endometriosis has also been noted, with a sixfold higher risk in women with first-degree relatives with severe endometriosis.2,3,6,7


Endometriosis is characterized by findings of endometrial tissue outside the normal uterine cavity. It may be diagnosed at any age, but is most commonly found during the reproductive years (range 12-80 years, average 28 years). Risk of developing endometriosis increases with early menarche (≤11 years), shorter menstrual cycles (less than 27 days), and heavy, prolonged menstruation.4,6,8 Conversely, higher parity and increased duration of lactation decrease the risk of endometriosis.4,6,8 Taller, thinner women are more likely to develop endometriosis than patients with higher body weights, body mass indexes, or waist-to-hip ratios potentially due to higher follicular-phase estradiol levels.6,8 The ...

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