The clinical manifestations of endometriosis depend on the distribution of the lesions. Extensive scarring of the fallopian tubes and ovaries often produces discomfort in the lower abdomen and eventual sterility. Rectal wall involvement may produce pain on defecation, whereas involvement of the uterine or bladder serosa can cause dyspareunia (painful intercourse) and dysuria, respectively. Almost all cases feature severe dysmenorrhea and pelvic pain resulting from intrapelvic bleeding and intraabdominal adhesions.
Women commonly seek medical attention for abnormal uterine bleeding, such as menorrhagia (profuse or prolonged bleeding at the time of the period), metrorrhagia (irregular bleeding between the periods), or postmenopausal bleeding. Common causes include dysfunctional uterine bleeding, endometrial polyps, leiomyomas, endometrial hyperplasia, and endometrial carcinoma.
The probable cause of uterine bleeding in any given case varies depending on the age of the patient (
Table 19.2 ). Abnormal bleeding from the uterus in the absence of an organic uterine lesion is called dysfunctional uterine bleeding. The most common cause of dysfunctional uterine bleeding is anovulation (failure to ovulate). Anovulatory cycles result from hormonal imbalances and are most common at menarche and in the perimenopausal period because of fluctuations in the hypothalamus/pituitary/ovarian axis. Less common causes of anovulation are
Endocrine disorders, such as thyroid disease, adrenal disease, or pituitary tumors.
Ovarian lesions, such as a functioning ovarian tumor (granulosa cell tumors) or polycystic ovarian syndrome (see section on that follows).
Generalized metabolic disturbances, such as obesity, malnutrition, or other chronic systemic disorders.
Dysfunctional uterine bleeding also may result from an inadequate luteal phase, which is thought to stem from
Table19.2CausesofAbnormalUterineBleedingbyAgeGroup
ReproductiveageComplicationsofpregnancy(abortion,trophoblasticdisease,ectopicpregnancy)Proliferations(leiomyoma,adenomyosis,polyps,endometrialhyperplasia,carcinoma)AnovulatorycycleOvulatorydysfunctionalbleeding(e.g.,inadequatelutealphase)
Proliferations(carcinoma,hyperplasia,polyps)
PostmenopauseProliferations(carcinoma,hyperplasia,polyps)Endometrialatrophy http://ebooksmedicine.net insufficient production of progesterone by the corpus luteum.
Adenomyosisreferstogrowthofendometriumintothemyometriumoftenwithuterineenlargement.
Endometriosisreferstoendometrialglandsandstromalocatedoutsidetheuterusandmostofteninvolvesthepelvicorabdominalperitoneum.Rarely,distantsitessuchasthelymphnodesandthelungsalsoareinvolved.
Theectopicendometriuminendometriosisundergoescyclicbleeding,andtheconditionisacommoncauseofdysmenorrheaandpelvicpain.
The most common proliferative lesions of the uterine corpus are endometrial hyperplasia, endometrial carcinomas, endometrial polyps, and smooth muscle tumors. All tend to produce abnormal uterine bleeding as their earliest manifestation.