Snapshot A 29-year-old nulligravida presents with severe pain with menses and an inability to conceive after 24 months of unprotected intercourse. She reports feeling pain with defecation and intercourse. On pelvic exam, her uterus is found to be retroverted and there is nodularity of the uterosacral ligament on retrovaginal examination. Introduction Clinical definition a nonmalignant condition where the endometrial glands and stroma are located outside of the uterus Epidemiology incidence 7-10% of women in the US demographics only in female most commonly in those 25-29 years of age location ovaries (most common) uterosacral ligaments retrouterine pouch (pouch of Douglas) peritoneum risk factors family history early menarche nulliparity Pathophysiology pathobiology ectopic endometrial tissue leads to an estrogen-stimulated inflammatory response Associated conditions chronic pelvic pain endometrioma ("chocolate cyst") endometriosis affecting the ovary subfertility Prognosis natural history of disease endometriosis may self-stabilize without treatment; however, this may be a progressive, relapsing, or chronic condition Presentation Symptoms dysmenorrhea dyspareunia (painful intercourse) dyschezia (painful defecation) infertility chronic pelvic pain Physical exam nodular thickening of uterosacral ligament a fixed retroverted uterus tender, fixed adnexal masses Imaging Ultrasonography indications first-line imaging modality to assess for endometriosis Studies Laparoscopic visualization with histologic confirmation provides definitive diagnosis of endometriosis classically may see "powder burn" appearance Histology endometrial glandular tissue Differential Adenomyosis Endometritis Ovarian torsion Treatment Medical combined hormonal or progestin-only contraceptives indications considered first-line for pain due to endometriosis gonadotropin-releasing hormone (GnRH) agonist indications second-line treatment for endometriosis mechanism inhibits gonadotropin secretion which decreases FSH and LH levels leading to a suppression of ovarian function levonorgestrel-releasing intrauterine device (IUD) indications another second-line treatment for endometriosis danazol indications not commonly used due to side-effects mechanism suppreses FSH and LH pituitary secretion Operative laparoscopic ablation indications surgery is the only definitive treatment and diagnostic modality total abdominal hysterectomy with lysis of adhesions indications in patients who have completed childbearing with severe and recurrent disease Complications Complications infertility