Emergent Treatment of Endometriosis

Endometriosis is a gynecologic disorder that is frequently encountered in the emergency department (ED) as well as in the outpatient setting. Because it is enigmatic, endometriosis can present as a diagnostic and therapeutic challenge for emergency physicians in their approach to the female patient with pelvic pain. ^{[1, 2, 3]}

Prior to ascribing a patient's abdominal or pelvic pain to endometriosis, the clinician should consider other important causes of such pain, including ectopic pregnancy, pelvic infection, and ovarian torsion. Patients may also have concomitant endometriosis and inflammatory bowel disease (stricturing Crohn disease). ^[4]

The most common sites of involvement in endometriosis, as seen on laparoscopic examination, are as follows, in descending order:

• Ovaries

• Posterior cul-de-sac

• Broad ligament

• Uterosacral ligament

• Rectosigmoid colon

• Bladder

• Distal ureter

Cases have been reported of extrapelvic involvement in virtually every other organ system including the central nervous system (CNS), lungs, pleura, kidney, and bladder. The gastrointestinal (GI) tract is the most common extrapelvic site of endometriosis, and symptoms include bowel obstruction, rectal bleeding, and constipation. ^[5]

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In the ED setting, few laboratory tests prove to be valuable in the diagnosis of endometriosis.

A complete blood cell (CBC) count with differential may help to differentiate pelvic infection from endometriosis and to assess the degree of blood loss, if any.

Urinalysis and urine culture should be sent if urinary tract infection (UTI) is in the differential diagnosis.

Cervical Gram stain and cultures should be considered, because sexually transmitted diseases (STDs) can also cause pelvic pain and infertility.

Beta human chorionic gonadotropin (HCG) can rule out pregnancy and its complications.

Radiography

Routine radiographs are not recommended unless other disease entities requiring these studies are in the differential diagnosis.

Ultrasonography

Endometriosis can be assessed by either transvaginal ultrasonography or endorectal ultrasonography. The ultrasonographic features of endometriomas vary from simple cysts to complex cysts with internal echoes to solid masses, usually devoid of vascularity. ^[6]

Magnetic resonance imaging

Magnetic resonance imaging (MRI) offers a superior combination of 3D imaging with high-resolution special and temporal resolution, low observer dependency, no radiation exposure, and none of the risks associated with iodinated contrast agents.

With dynamic contrast-enhanced MRI, dynamic changes in MR signal intensity in selected tissues can be detected. Some of the newer generation contrast agents can be loaded with specific antibodies that allow for targeted imaging.

MRI has a higher sensitivity for detecting pelvic masses than ultrasonography but is limited in identifying diffuse pelvic endometriosis.

Computed tomography scanning

Using computed tomography (CT) scanning, endometriomas may appear as cystic masses, but their appearance is nonspecific, and CT scanning should not be relied on for diagnosis.

Complications of endometriosis, including bowel obstruction and hydronephrosis, may be seen on CT scans. ^[7]

Hysterosalpingography

Hysterosalpingography may reveal tubal occlusion or periadnexal adhesions.

Laparoscopy with biopsy is the only definitive way to diagnose endometriosis. It is an invasive procedure with an overall sensitivity of 97% and a specificity of only 77%. Hallmark findings are the classic powder burn, blue-black lesions.

Prehospital care

Follow established protocols of resuscitation for unstable female patients of reproductive age with acute abdominal/pelvic pain.

Emergency department care

The goal of the emergency physician is to provide pain relief and exclude life-threatening causes of pelvic/abdominal pain. Unstable patients require resuscitation and possibly urgent surgical consult.

Medical management in the ED generally is restricted to pain control. Long-term medical therapy usually is suppressive and rarely curative.

Medical treatments for endometriosis act in a variety of ways to abolish the trophic effect of estradiol on the eutopic and ectopic endometrium. Therefore, the patient develops amenorrhea, because all endometrial tissue becomes inactive.

Although medical treatment can relieve symptoms, the recurrence rate is high after cessation of medications. ^[8]  All medical treatments are equally effective in managing endometriosis; about 80-85% of patients note improvement in their symptoms. The main difference between medical treatments is their side-effect profile.

Medical treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), progestins (ie, medroxyprogesterone), combination estrogens and progestins, synthetic androgens (ie, danazol), and gonadotropin-releasing hormone analogues with or without hormone replacement therapy. Alternative therapies such as transcutaneous electrical nerve stimulation (TENS) (acupuncture-like TENS, self-applied TENS) may be effective complementary treatments for women with deep endometriosis who have persistent pelvic pain and/or deep dyspareunia despite undergoing hormone therapy. ^[9]

Urgent acute complications of endometriosis during pregnancy include spontaneous hemoperitoneum and bowel and ovarian complications that often require operative intervention. ^[3]

Surgical management can be either conservative (ie, laparoscopy with lysis of adhesions) or definitive (ie, total abdominal hysterectomy with bilateral salpingo-oophorectomy [TAH/BSO]).

The fact that TAH/BSO relieves the symptoms of endometriosis is well established. In some cases, however, not all of the endometrial tissue implanted outside the uterus can be removed, and symptoms may persist.

Patients may require surgery involving dissection of the urinary tract, bowel, and/or rectovaginal septum.

There is some degree of recurrence even after surgical therapy. ^[8]

Stable patients with the presumptive diagnosis of endometriosis require gynecologic referral for long-term management. ^{[10, 11]}

Medication

Medication management beyond pain control is outside the scope of emergency medicine. Patients should have their pain controlled and be referred to a gynecologist for further management.