Endometriosis
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Endometriosis
Classification and alien resources
ICD-10 N80.
ICD-9 617.0
OMIM 131200
DiseasesDB 4269
MedlinePlus 000915
eMedicine med/3419 ped/677 emerg/165
MeSH D004715

Endometriosis (from endo, "inside", and metra, "womb") is a medical activity in females in which endometrial like cells arise and curl in areas alfresco the uterine cavity, a lot of frequently on the ovaries. The uterine atrium is lined by endometrial cells, which are beneath the access of changeable hormones. These endometrial-like beef in areas alfresco the uterus (endometriosis) are afflicted by hormonal changes and acknowledge analogously as do those beef begin axial the uterus. Affection about aggravate in time with the menstrual cycle.

Endometriosis is about apparent during the changeable years; it has been estimated that it occurs in almost 5% to 10% of women.1 Affection may depend on the website of animate endometriosis. Its capital but not accustomed affirmation is pelvic pain in assorted manifestations. Endometriosis is a common award in women with infertility.

Contents

Symptoms

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Pelvic pain

A aloft affirmation of endometriosis is alternating pelvic pain. The affliction can be balmy to astringent airtight that occurs on both abandon of the pelvis, to the lower aback and belly breadth and even down the legs. The bulk of affliction a woman feels is not necessarily accompanying to the admeasurement or date (1 through 4) of endometriosis. Some women will accept little or no affliction admitting accepting all-encompassing endometriosis affecting ample areas or accepting endometriosis with scarring. On the added hand, women may accept astringent affliction even admitting they accept abandoned a few baby areas of endometriosis. However, affliction does about aggravate with severity. Affection of endometriosic-related affliction may awning 2:

Infertility

Many women with infertility accept endometriosis. As endometriosis can advance to anatomical distorsions and adhesions (the coarse bands that analysis amid tissues and organs afterward accretion from an injury), the agent may be simple to understand; however, the hotlink amid infertility and endometriosis charcoal ambiguous if the admeasurement of endometriosis is limited.3 It has been adapted that endometriotic lesions absolution factors which are adverse to gametes or embryos, or, alternatively, endometriosis may added acceptable advance in women who abort to accept for added affidavit and appropriately be a accessory phenomenon; for this acumen it is bigger to allege of endometriosis-associated infertility4 in such cases.



Other

Other affection may be present, including:

In addition, women who are diagnosed with endometriosis may accept gastrointestinal affection that actor annoyed bowel syndrome

Patients who breach an endometriotic cyst may present with an acute abdomen as a medical emergency.

Occasionally affliction may aswell activity in added regions. Cysts can activity in the float (although rare) and could could could could could could could could could could cause affliction and even bleeding during urination. Endometriosis can access the intestinecitation needed and could could could could could could could could could could cause aching bowel movements or diarrhea.

In accession to affliction during menstruation, the affliction of endometriosis can activity at added times of the ages and doesn't accept to be just on the date on menses. There can be affliction with ovulation, affliction associated with adhesions, affliction acquired by deepening in the pelvic cavity, affliction during bowel movements and urination, during accustomed actual movement i.e. exercise, affliction from continuing or walking, and affliction with intercourse. But the a lot of atrocious affliction is usually with menstruation and abounding women alarming accepting their periods. Aswell the affliction can alpha a anniversary afore menses, during and even a anniversary afterwards menses, or it can be constant. There is no accustomed cure for endometriosis.citation needed

Epidemiology

Endometriosis can affect any female, from premenarche to postmenopause, behindhand of chase or ethnicity or whether or not they accept had children. It is primarily a ache of the changeable years. Estimates about its prevalence vary, but 5–10% is a reasonable number, added accustomed in women with infertility (20–50%) and women with abiding pelvic affliction (about 80%).6 As an estrogen-dependent process, it can abide aloft menopause and persists in up to 40% of patients afterward hysterectomy.7


Endometriosis and Smoking

This activity is associated with tobacco smoker in women. The accident of a cyst axis to be ovarian blight is acutely top in such altitude abnormally in women in their 30's. Ovarian cysts may announce avant-garde endometriosis and about is associated with bargain abundance or infertility.Smoking causes decreased estrogens with advance bleeding and beneath luteal phases. Smokers accept an beforehand than accustomed (by about 1.5-3 years) menopause which suggests that there is some baneful affect of smoker on the follicles directly. Chemically, nicotine has been apparent to administer in cervical close and metabolites accept been begin in follicular aqueous and been associated with delayed follicular advance and maturation. Finally, there is some affect on tubal activity because smoker is associated with an added accident of ectopic abundance as able-bodied as an added ad-lib aborticide rate.


Endometriosis and Pregnancy

It is absolutely accustomed for women to accompany educational and career opportunities and put off bearing into the backward 20's and aboriginal 30's. Aging, however, brings with it abounding furnishings that will abatement fertility. Depletion over time of ovarian follicles affects menstrual regularity. Endometriosis has added time to aftermath scarring of the ovary and tubes so they cannot move advisedly or it can even alter ovarian follicular tissue if ovarian endometriosis persists and grows. Leiomyomata (fibroids) can boring abound and alpha causing endometrial bleeding that disrupts article sites or distorts the endometrial atrium which affects accustomed a abundance in the actual aboriginal stages. Belly adhesions from added intraabdominal surgery, or burst ovarian cysts can aswell affect tubal activity bare to ambit the ovary and accumulate an ovulated corpuscle (egg).

Endometriosis in postmenopausal women does activity and has been declared as an advancing analysis of this ache characterized by complete progesterone attrition and abnormally top levels of aromatase expression.8 In beneath accustomed cases, girls may accept endometriosis affection afore they even ability menarche.910

Co-morbidity

Endometriosis bears no accord to endometrial cancer. Accustomed analysis has accustomed an affiliation amid endometriosis and assertive types of cancers, conspicuously ovarian cancer, non-Hodgkin's lymphoma and brain cancer.111213 Endometriosis about aswell coexists with leiomyoma or adenomyosis, as able-bodied as autoimmune disorders. A 1988 analysis conducted in the US begin decidedly added Hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma in women with endometriosis compared to the accustomed population.14

Pathology and locations

Endoscopic angel of endometriotic lesions at the peritoneum of the pelvic wall.
Micrograph of the bank of an endometrioma. All actualization of endometriosis are present (endometrial glands, endometrial stroma and hemosiderin-laden macrophages. H&E stain.

Active endometriosis produces anarchic mediators that could could could could could could could could could could cause affliction and inflammation, as able-bodied as scarring or fibrosis of surrounding tissue. Triggers of assorted kinds, including menses, toxins, and accustomed factors, may be all-important to alpha this process. Typical endometriotic lesions actualization histologic actualization agnate to endometrium, namely stroma, endometrial epithelium, and glands that acknowledge to hormonal stimuli. Older lesions may affectation no glands but hemosiderin deposits as residual. To the eye, lesions can arise aphotic dejected or powder-burn atramentous and alter in size; red, white, yellow, amber or non-pigmented. Some lesions aural the belly walls may not be arresting to the eye, as normal-appearing abdominals of barren women reveals endometriosis on biopsy in 6–13% of cases.15 Additionally added lesions may be present, conspicuously endometriomas of the ovary, blister formation, and peritoneal defects or pockets. Endometrioma on the ovary of any cogent admeasurement (Approx. 2 cm +) accept to be removed surgically because hormonal analysis abandoned will not abolish the abounding endometrioma cyst, which can advance to astute affliction from the rupturing of the cyst and centralized bleeding. Endometrioma is sometimes misdiagnosed as ovarian cysts.

Early endometriosis about occurs on the surfaces of organs in the pelvic and intra-abdominal areas. Bloom affliction providers may alarm areas of endometriosis by altered names, such as implants, lesions, or nodules. Beyond lesions may be apparent aural the ovaries as endometriomas or "chocolate cysts", "chocolate" because they accommodate a blubbery brownish fluid, mostly old blood. Endometriosis may activate anarchic responses arch to blister accumulation and adhesions.

Endoscopic angel of endometriotic lesions in the Pouch of Douglas and on the adapted sacrouterine ligament.

Most endometriosis is begin on these structures in the pelvic cavity breadth it can aftermath mild, moderate, and/or astringent affliction acquainted in the belly and/or lower aback areas. The affliction is about added astringent before, during, and/or afterwards the menstrual period:

Bowel endometriosis affects about 10% of women with endometriosis, and can could could could could could could could could could could cause astringent affliction with bowel movements.

Endometriosis may advance to the cervix and vagina or to sites of a surgical belly incision.

Less frequently lesions can be begin on the diaphragm. Diaphragmatic endometriosis is rare, a lot of consistently on the adapted hemidiaphragm, and may administer circadian affliction of the adapted accept just afore and during menses. Rarely, endometriosis can be extraperitoneal and is begin in the lungs and CNS.16

Pleural implantations are associated with alternate adapted pneumothoraces at times of menses, termed catamenial pneumothorax.

Endometriosis may aswell present with derma lesions in cutaneous endometriosis.

Complications

Endoscopic angel of a burst chocolate cyst in larboard ovary.

Complications of endometriosis include:

Infertility can be accompanying to blister accumulation and anatomical distortions due to the endometriosis; however, endometriosis may aswell baffle in added attenuate ways: cytokines and added actinic agents may be appear that baffle with reproduction.

Complications of endometriosis awning bowel and ureteral obstruction consistent from pelvic adhesions. Also, peritonitis from bowel breach can occur.

Diagnosis

A bloom history and a concrete assay can in abounding patients advance the physician to doubtable endometriosis. Anaplasty is the gold accustomed in diagnosis. However, a lot of allowance affairs will not awning surgical analysis unless the accommodating has already attempted to become abundant and failed.

Micrograph an endometrioma. H&E stain.

Use of imaging tests may analyze endometriotic cysts or beyond endometriotic areas. It aswell may analyze chargeless aqueous about aural the cul-de-sac. The two a lot of accustomed imaging tests are ultrasound and magnetic resonance imaging (MRI). Accustomed after-effects on these tests do not annihilate the achievability of endometriosis. Areas of endometriosis are about too baby to be apparent by these tests.

The abandoned way to analyze endometriosis is by laparoscopy or added types of anaplasty with bane biopsy. The analysis is based on the adapted actualization of the disease, and should be corroborated by a biopsy. Anaplasty for diagnoses aswell allows for surgical analysis of endometriosis at the aforementioned time.

Although doctors can about feel the endometrial growths during a pelvic exam, and your affection may be admonition signs of endometriosis, analysis cannot be accustomed afterwards assuming a laparoscopic procedure. About the affection of ovarian blight are identical to those of endometriosis. If a misdiagnosis of endometriosis occurs due to abortion to affirm analysis through laparoscopy, aboriginal analysis of ovarian cancer, which is acute for acknowledged treatment, may accept been missed.18

Staging

Surgically, endometriosis can be staged I–IV (Revised Allocation of the American Society of Changeable Medicine).19 The activity is a circuitous point arrangement that assesses lesions and adhesions in the pelvic organs, but it is important to agenda staging assesses concrete ache only, not the akin of affliction or infertility. A accommodating with Date I endometriosis may accept little ache and astringent pain, while a accommodating with Date IV endometriosis may accept astringent ache and no affliction or carnality versa. In assumption the assorted stages actualization these findings:

Findings belted to abandoned apparent lesions and possibly a few chiffon adhesions
In addition, some abysmal lesions are present in the cul-de-sac
As above, added attendance of endometriomas on the ovary and added adhesions
As above, added ample endometriomas, all-encompassing adhesions.

Markers

An breadth of analysis is the seek for endometriosis markers. These markers are substances fabricated by or in acknowledgment to endometriosis that bloom affliction providers can admeasurement in the claret or urine. If markers are found, bloom affliction providers could analyze endometriosis by testing a woman's claret or urine which ability actualization top levels of estrogen or low levels of progesterone, and allay the charge for surgery. The antigen CA-125 is accustomed to be animated in abounding patients with endometriosis20 but is not accurately apocalyptic of endometriosis.

Research is aswell getting conducted on abeyant abiogenetic markers associated with endometriosis so that a saliva-based analytic may alter surgical procedures for basal diagnosis.21 However, this analysis charcoal actual basic and the analytic accustomed continues to be surgical intervention.

Potential causes

While the exact could could could could could could could could could could cause of endometriosis charcoal unknown, abounding theories accept been presented to bigger accept and explain its development. These concepts do not necessarily exclude anniversary other.

  1. Estrogens: Endometriosis is a activity that is estrogen-dependent and appropriately apparent primarily during the changeable years. In beginning models, estrogen is all-important to abet or advance endometriosis. Medical analysis is about aimed at blurred estrogen levels to ascendancy the disease. Additionally, the accustomed analysis into aromatase, an estrogen-synthesizing enzyme, has provided affirmation as to why and how the ache persists afterwards menopause and hysterectomy.
  2. Retrograde menstruation: The access of astern menstruation, aboriginal proposed by John A. Sampson, suggests that during a woman's menstrual flow, some of the endometrial bits exits the uterus through the fallopian tubes and attaches itself to the peritoneal apparent (the lining of the belly cavity) breadth it can advance to access the tissue as endometriosis. While a lot of women may accept some astern menstrual flow, about their accustomed arrangement is able to bright the bits and anticipate article and advance of beef from this occurrence. However, in some patients, endometrial tissue crude by astern menstruation may be able to implant and authorize itself as endometriosis. Factors that ability could could could could could could could could could could cause the tissue to abound in some women but not in others charge to be studied, and some of the accessible causes beneath may accommodate some explanation, e.g., ancestral factors, toxins, or a compromised accustomed system. It can be argued that the ceaseless accident of accustomed menstruation ages afterwards ages for decades is a avant-garde phenomenon, as in the accomplished women had added accustomed menstrual blow due to abundance and lactation. Sampson's access absolutely is not able to explain all instances of endometriosis, and it needs added factors such as abiogenetic or accustomed differences to anniversary for the actuality that abounding women with astern menstruation do not accept endometriosis. In addition, at atomic one abstraction begin that endometriotic lesions are biochemically actual altered from crude ectopic tissue, which casts agnosticism on Sampson's theory.22
  3. Müllerianosis: A aggressive access states that beef with the abeyant to become endometrial are laid down in tracts during beginning development and organogenesis. These tracts chase the changeable changeable (Mullerian) amplitude as it migrates caudally (downward) at 8–10 weeks of beginning life. Primitive endometrial beef become confused from the brief uterus and act like seeds or stem cells. This access is accurate by foetal autopsy.23
  4. Coelomic Metaplasia: This access is based on the actuality that coelomic epithelium is the accustomed antecedent of endometrial and peritoneal beef and hypothesizes that afterwards metaplasia (transformation) from one blazon of corpuscle to the added is possible, conceivably triggered by inflammation.1 This access is added accurate by class ascertainment of this transformation.24
  5. Genetics: Ancestral factors play a role. It is able-bodied accustomed that daughters or sisters of patients with endometriosis are at college accident of developing endometriosis themselves; for example, low progesterone levels may be genetic, and may accord to a hormone imbalance. There is an about 10-fold added accident in women with an afflicted first-degree relative.6 A 2005 abstraction appear in the American Journal of Animal Genetics begin a hotlink amid endometriosis and chromosome 10q26.25 One abstraction begin that in changeable ancestors of patients with endometriosis the relative risk of endometriosis is 5.7:1 against a ascendancy population.26
  6. Transplantation: It is accustomed that in specific patients endometriosis can advance directly. Appropriately endometriosis has been begin in belly incisional scars afterwards anaplasty for endometriosis. It can aswell abound invasively into altered tissue layers, i.e., from the cul-de-sac into the vagina. On attenuate occasions endometriosis may be crude by blood or by the lymphatic system into borderline organs such as the lungs and brain.
  7. Immune system: Analysis is absorption on the achievability that the immune system may not be able to cope with the circadian aggression of astern menstrual fluid. In this ambience there is absorption in belief the accord of endometriosis to autoimmune disease, allergic reactions, and the appulse of toxins.27 It is still cryptic what, if any, causal accord exists amid toxins, autoimmune disease, and endometriosis.
  8. Environment: There is a growing suspicion that ecology factors may could could could could could could could could could could cause endometriosis, accurately some plastics and affable with assertive types of artificial containers with microwave ovens.28 Added sources advance that pesticides and hormones in our aliment could could could could could could could could could could cause a hormone imbalance.
  9. Birth Defect: In attenuate cases breadth imperforate hymen does not boldness itself above-mentioned to the aboriginal menstrual aeon and goes undetected, claret and endometrium are trapped aural the uterus of the accommodating until such time as the botheration is apprenticed by surgical incision. Abounding bloom affliction practitioners never appointment this defect, and due to the flu-like symptoms it is about misdiagnosed or disregarded until assorted menstrual cycles accept passed. By the time a actual analysis has been made, endometrium and added fluids accept abounding the uterus and fallopian tubes with after-effects agnate to astern menstruation consistent in endometriosis. The antecedent date of endometriosis may alter based on the time delayed amid access and surgical procedure.

Cause of pain

The way endometriosis causes affliction is the accountable of abundant research. Because abounding women with endometriosis feel affliction during or about their periods and may discharge added menstrual breeze into the belly with anniversary menstruation, some advisers are aggravating to allay menstrual contest in patients with endometriosis.

Endometriosis lesions acknowledge to hormonal dispatch and may "bleed" at the time of menstruation. The claret accumulates locally, causes swelling, and triggers anarchic responses with the activation of cytokines. It is anticipation that this activity may could could could could could could could could could could cause pain.

Pain can aswell activity from adhesions (internal blister tissue) bounden centralized organs to anniversary other, causing agency dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the float can be apprenticed calm in means that are aching on a circadian basis, not just during menstrual periods.

Treatments

While there is no cure for endometriosis,citation needed in abounding patients menopause (natural or surgical) will allay the process. In patients in the changeable years, endometriosis is artlessly managed: the ambition is to accommodate affliction relief, to bind progression of the process, and to abate infertility if that should be an issue. In adolescent women with annoyed changeable potential, surgical analysis tends to be conservative, with the ambition of removing endometrial tissue and absorption the ovaries afterwards damaging accustomed tissue. In women who do not accept charge to advance their changeable potential, hysterectomy and/or abatement of the ovaries may be an option; however, this will not agreement that the endometriosis and/or the affection of endometriosis will not appear back, and anaplasty may abet adhesions which can advance to complications.

In general, patients are diagnosed with endometriosis at time of surgery, at which time ablative accomplish can be taken. Added accomplish depend on circumstances: patients afterwards infertility can be managed with hormonal medication that abolish the accustomed aeon and affliction medication, while barren patients may be advised expectantly afterwards surgery, with abundance medication, or with IVF.

Sonography is a adjustment to adviser ceremony of endometriomas during treatments.

Treatments for endometriosis in women who do not ambition to become abundant include:

Hormonal medication

Other medication

Surgery

Procedures are classified as

Conservative analysis consists of removal, abatement or ablation of endometriosis, adhesions, resection of endometriomas, and apology of accustomed pelvic analysis as abundant as is possible.3

Radical analysis in endometriosis removes the uterus (hysterectomy) and tubes and ovaries (bilateral salpingo-oophorectomy) and appropriately the adventitious for reproduction. Abolitionist anaplasty is about aloof for women with abiding pelvic affliction that is disabling and treatment-resistant. Not all patients with abolitionist anaplasty will become pain-free.

Semi-conservative analysis preserves a advantageous actualization ovary, and yet, it aswell increases the accident of recurrence.32

For patients with astute pain, a presacral neurectomy may be adumbrated breadth the fretfulness to the uterus are cut. However, able analytic affirmation showed that presacral neurectomy is added able in affliction abatement if the pelvic affliction is midline concentrated, and not as able if the affliction extends to the larboard and adapted lower quadrants of the abdomen.3 This is due to the actuality that the fretfulness to be transected in the activity are innervating the axial or the midline arena in the changeable pelvis. Furthermore, women who had presacral neurectomy accept college prevalence of abiding ache not responding able-bodied to medication analysis because of the abeyant abrasion to the parasympathetic assumption in the around during the procedure.

Comparison of alleviative and surgical interventions

Efficacy studies actualization that both alleviative and surgical interventions aftermath almost agnate pain-relief benefits. Ceremony of affliction was begin to be 44 and 53 percent with alleviative and surgical interventions, respectively.6 However, anniversary access has its own advantages and disadvantages.1

Advantages of alleviative interventions

  1. Decrease antecedent cost
  2. Empirical analysis (i.e. Can be calmly adapted as needed)
  3. Effective for affliction control

Disadvantages of alleviative interventions

  1. Adverse furnishings are common
  2. Not acceptable to advance fertility
  3. Some can abandoned be acclimated for apprenticed periods of timecitation needed

Advantages of surgery

  1. Has cogent ability for affliction control.33
  2. Has added ability over alleviative activity for infertility treatment
  3. Combined with biopsy, it is the abandoned way to accomplish a absolute diagnosis

Disadvantages of surgery

  1. Cost
  2. Risks are "poorly defined... and apparently underestimated." In one study, 3-10% accomplished aloft complications from surgery.34
  3. Efficacy is questionable. In the aforementioned study, abundant concise affliction abatement was accomplished by about 70-80% of the subjects. However, at 1 year follow-up, about 50% of the capacity bare analgesics or hormonal treatments.34

Treatment of infertility

While almost agnate to alleviative interventions in alleviative pain, the ability of anaplasty is abnormally cogent in alleviative infertility. One abstraction has apparent that surgical analysis of endometriosis about doubles the fecundity (pregnancy rate).35 The use of medical abolishment afterwards anaplasty for minimal/mild endometriosis has not apparent allowances for patients with infertility.4 Use of abundance medication that stimulates ovulation (clomiphene citrate, gonadotropins) accumulated with intrauterine insemination (IUI) enhances abundance in these patients.4

In-vitro fertilization (IVF) procedures are able in convalescent abundance in abounding women with endometriosis. IVF makes it accessible to amalgamate agent and eggs in a class and again abode the consistent embryos into the woman's uterus. The accommodation if to administer IVF in endometriosis-associated infertility takes into anniversary the age of the patient, the severity of the endometriosis, the attendance of added infertility factors, and the after-effects and continuance of accomplished treatments.

Other treatments

Prognosis

Proper counseling of patients with endometriosis requires absorption to several aspects of the disorder. Of primary accent is the antecedent accessible staging of the ache to access able advice on which to abject approaching decisions about therapy. The patient's affection and admiration for bearing behest adapted therapy. Not all analysis works for all patients. Some patients accept reoccurrences afterwards anaplasty or pseudo-menopause. In a lot of cases, analysis will accord patients cogent abatement from pelvic affliction and abetment them in accomplishing pregnancy.40 It is important for patients to be always in acquaintance with their physician and accumulate an accessible chat throughout treatment. This is a ache afterwards a cure but with the able communication, one with endometriosis can attack to reside a normal, activity life.

Recurrence

The basal activity that causes endometriosis may not cease afterwards surgical or medical intervention, and the anniversary ceremony amount is accustomed as 5–20 % per year extensive eventually about 40% unless hysterectomy is performed or menopause reached.3 Monitoring of patients consists of alternate analytic examinations and sonography. Also, the CA 125 serum antigen levels accept been acclimated to chase patients with endometriosis.

Endometriosis in the male

Endometriosis has been declared in men accepting a actual top estrogen medication (TACE) as allotment of analysis for prostatic cancer.41

Additional images

Endometriosis, belly wall

See also

References

  1. ^ a b c Diagnosis and Analysis of Endometriosis - October 15, 1999 - American Academy of Family Physicians
  2. ^ Endometriosis;NIH Pub. No. 02-2413; September 2002
  3. ^ a b c d Speroff L, Glass RH, Kase NG (1999). Clinical Gynecologic Endocrinology and Infertility (6th ed.). Lippincott Willimas Wilkins. p. 1057. ISBN 0-683-30379-1. 
  4. ^ a b c Buyalos RP, Agarwal SK (October 2000). "Endometriosis-associated infertility". Current Opinion in Obstetrics & Gynecology 12 (5): 377–81. doi:10.1097/00001703-200010000-00006. ISSN 1040-872X. PMID 11111879. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1040-872X&volume=12&issue=5&spage=377. 
  5. ^ Possover & Henle; "Outlet ache affection acquired by addendum of the rectosigmoide as a accustomed analysis for pelveo-abdominal affliction and abdominal troubles in women with endometriosis";Gynecologic Surgery, Volume 6, Amount 3 / September, 2009; DOI:10.1007/s10397-009-0474-6
  6. ^ a b c Dharmesh Kapoor and Willy Davila, 'Endometriosis', eMedicine (2005).
  7. ^ "Endometriosis - Hysterectomy". Umm.edu. http://www.umm.edu/patiented/articles/what_radical_surgery_hysterectomy_endometriosis_000074_11.htm. Retrieved 2009-08-19. 
  8. ^ Bulun SE, Zeitoun K, Sasano H, Simpson ER (1999). "Aromatase in crumbling women". Seminars in Changeable Endocrinology 17 (4): 349–58. ISSN 0734-8630. PMID 10851574. 
  9. ^ Batt RE, Mitwally MF (December 2003). "Endometriosis from thelarche to midteens: pathogenesis and prognosis, blockage and pedagogy". Journal of Pediatric and Adolescent Gynecology 16 (6): 337–47. doi:10.1016/j.jpag.2003.09.008. ISSN 1083-3188. PMID 14642954. 
  10. ^ Marsh EE, Laufer MR (March 2005). "Endometriosis in premenarcheal girls who do not accept an associated adverse anomaly". Fertility and Sterility 83 (3): 758–60. doi:10.1016/j.fertnstert.2004.08.025. ISSN 0015-0282. PMID 15749511. 
  11. ^ "Endometriosis blight risk". medicalnewstoday.com. 5 July 2003. http://www.medicalnewstoday.com/medicalnews.php?newsid=3890. Retrieved 2007-07-03. 
  12. ^ Roberts, Michelle (3 July 2007). "Endometriosis 'ups blight risk'". BBC News. BBC / news.bbc.co.uk. http://news.bbc.co.uk/2/hi/health/6262140.stm. Retrieved 2007-07-03. 
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  14. ^ Sinaii N, Cleary SD, Ballweg ML, Nieman LK, Stratton P (October 2002). "High ante of autoimmune and endocrine disorders, fibromyalgia, abiding fatigue affection and atopic diseases a part of women with endometriosis: a analysis analysis" (Free abounding text). Human Reproduction 17 (10): 2715–24. doi:10.1093/humrep/17.10.2715. ISSN 0268-1161. PMID 12351553. http://humrep.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12351553. 
  15. ^ Nisolle M, Paindaveine B, Bourdon A, Berlière M, Casanas-Roux F, Donnez J (June 1990). "Histologic abstraction of peritoneal endometriosis in barren women". Fertility and Sterility 53 (6): 984–8. ISSN 0015-0282. PMID 2351237. 
  16. ^ Shawn Daly, MD, Consulting Staff, Catalina Radiology, Tucson, Arizona (October 18 2004). "Endometrioma/Endometriosis". WebMD. http://www.emedicine.com/radio/topic250.htm. Retrieved 2006-12-19. 
  17. ^ Lone Hummelshoj. "Adhesions in Endometriosis". endometriosis.org. http://www.endometriosis.org/adhesions.html. Retrieved 2009-04-25. 
  18. ^ Warren Volker, OB/GYN MD Endometriosis Analysis and Cure
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  21. ^ [1]dead link
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