- What is the pathologic process?
The images show areas of endometriosis.
- What three histologic elements can be found in this condition?
The three elements of endometriosis are endometrial-type glands, endometrial type stroma, and hemosiderin (or hemorrhage). At least two of the three elements should be present to make the diagnosis.
- What is the pathogenesis of this condition?
The condition is thought to arise from either regurgitation of endometrial tissue into the peritoneal cavity via the fallopian tube during menses, embryologic Mullerian rests, metaplasia of the peritoneal mesothelium, or hematogenous/lymphatic dissemination of endometrial tissue. Endometriosis tissue may bleed at the time of menses, in contrast to adenomyosis tissue, which usually does not cycle. There is a strong association with infertility.
- What can be done for this condition?
In patients with pelvic pain, in whom endometriosis is a possibility, use of oral contraceptives and anti-inflammatory pain medications can be used. If such medications do not control the pain, then a pharmacologic agent such as danazol that attenuates the mid-cycle LH surge may be useful. A drug such as medroxyprogesterone that induces decidualization of the endometriotic foci with eventual atrophy may help.
In patients with pelvic pain and infertility, laparoscopy to find possible endometriotic foci is useful. Obliteration of the foci typically relieves the pain. Some patients may remain infertile and require assisted reproduction.
- What do you tell the patient if she says that all her previous doctors told her she did not have endometriosis but that it was "all in your head"?
Endometriosis is a disease that, in the past, often inspired a lack of empathy on the part of physicians. It is always a disease of women, and when doctors were mostly men, they tended to not be as empathetic as women. When the patient was a woman with 'female complaints' it made the unconscious sexism of medicine even worse. Empathy has become more respectable, perhaps because there are more women in medicine, or perhaps due to the same social causes that led to more women doctors: a decline in sexism in society, a decline in our overvaluation of masculine qualities like objectivity and being unemotional, and an increase in our valuation of feminine qualities like empathy.
What if you see a patient and realize she has endometriosis and that her previous doctors missed it completely? If you are confident in your diagnosis, tell her. But remember how easy it is to have some residual, subtle, culturally reinforced views that, no matter how much professionals don't like to face it, are sexist, and that this can and does often affect the quality of care.
