Endometriosis Diagnosis
A 33-year-old nulliparous woman reports cyclic pelvic pain, painful defecation during menses and deep dyspareunia for 3 years. Examination shows a fixed retroverted uterus with tender nodules in the posterior fornix. Diagnostic laparoscopy reveals bluish-black powder-burn lesions over the pelvic peritoneum with dense adhesions. Which of the following is the most likely diagnosis?
- A.Pelvic tuberculosis
- B.Adenomyosis
- C.Pelvic inflammatory disease
- D.EndometriosisCorrect
Explanation
Endometriosis is the presence of endometrial glands and stroma outside the uterine cavity, most often on the pelvic peritoneum, ovaries and uterosacral ligaments. Because the ectopic tissue responds to cyclical ovarian hormones, it bleeds with menstruation and provokes local inflammation and fibrosis, which explains the cyclic timing of the pain, the dyschezia when deposits involve the rectovaginal septum or uterosacral ligaments, and deep dyspareunia. Chronic scarring produces the fixed retroverted uterus and tender nodular uterosacral ligaments found here. Laparoscopy shows the classic bluish-black powder-burn lesions, along with red vesicular or white fibrotic implants, chocolate cysts of the ovary and adhesions, and remains the reference standard for diagnosis, though empirical treatment without laparoscopy is now accepted when the clinical picture is typical. Subfertility is a frequent accompaniment. Adenomyosis is endometrial tissue within the myometrium, presenting with a diffusely enlarged boggy tender uterus and heavy painful periods, and it is not seen on the peritoneal surface. Pelvic inflammatory disease causes constant rather than cyclic pain with fever, purulent discharge and cervical motion tenderness, and the laparoscopic appearance is inflamed oedematous tubes with pus, not powder-burn implants. Pelvic tuberculosis produces caseating tubercles with miliary nodules, infertility, amenorrhoea and constitutional symptoms.
Why each option
- A.
- Pelvic tuberculosis causes infertility, amenorrhea and constitutional symptoms, and laparoscopy shows caseating miliary tubercles rather than powder-burn implants.
- B.
- Adenomyosis involves endometrial tissue within the myometrium and gives a diffusely enlarged tender uterus with heavy painful menses, not peritoneal lesions.
- C.
- Pelvic inflammatory disease produces constant pain with fever, purulent discharge and cervical motion tenderness, and laparoscopy shows inflamed tubes with pus.
- D.
- Correct. Cyclic pelvic pain, dyschezia and dyspareunia with uterosacral nodularity and powder-burn peritoneal lesions on laparoscopy are diagnostic of endometriosis.
Reference: ESHRE Guideline on Endometriosis, 2022; Berek and Novak's Gynecology, 17th ed., 2024
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