Endometriosis is a disease where endometrium is placed
outside the uterus, usually in the pelvis. However, it can
be found in remote places outside the pelvis, and the
diagnosis of endometriosis may elude the treating physician,
unless the cyclical nature of the illness alerts the
physician of the possibility of extrapelvic endometriosis.
Although, endometriotic lesions get activated cyclically, in
some case reports, endometriotic lesions have known to
produce symptoms in the intermenstrual period also, giving
rise to a confusing clinical picture. Quite often, the
diagnosis is made incidentally on histology after surgery.
Since the symptoms are intermittent, it is also difficult to
convince the patient of the need for surgery.
extrapelvic sites are the pleura, lungs, breasts,
extremities, abdominal scars, the perineal region,
particularly in episiotomy scars, gallbladder, central
nervous system, extremities, perineum, and the abdominal
wall. It has presented in inguinal and umbilical hernias.
Endometrial tissue has also been identified in numerous
surgical or procedural scars,including Cesarean section,
laparoscopic trocar tract,a mniocentesis needle tract, and
perineal episiotomy incisions. Beside the unusual locations
of endometriotic lesions, the activation of endometriosis in
a non estrogenic milieu can also be considered uncommon.
For example, endometriosis is normally quiescent in
menopause and pregnancy, but there are rare case reports of
these lesions having got activated during these periods, viz:
menopause and pregnancy.
Endometriosis is known to occur at various sites on the
skin. The lesions may cause cyclical pain, but sometimes
they cause constant pain. They generally present to the
general surgeon, who excises thelesion, and a diagnosis of
endometriosis is made on histopathology.
Endometriosis in Abdominal wall:
Endometriotic lesions have been found in the abdominal wall,
both in patients who have undergone previous surgery on the
uterus, and also in patients who have not had any surgery on
theories of abdominal wall endometriosis have been put
forward. The transport theory states that endometrial cells
may be transported to distant locations after
retrograde regurgitation through the fallopian tubes,
vascular/lymphatic spread, or direct implantation through
where they proliferate to form endometriomas1,.
This may follow surgery on the uterus, like caesarian
section, after which the endometrium is transported to the
abdominal wall. The metaplasia theory suggests that
primitive pleuropotential mesenchymal cells undergo
specialized differentiation metaplasia to form endometrial
implants. Whatever the origin,the lesions respond to
pathological characteristic of abdominal incision
endometriosis appears as periodic haemorrhage of the ectopic
endometrium and fibrosis of the focus2. The focus
often involves the abdominal rectus and its sheath. The
superficial focus even breaks through skin and can be
observed as hemorrhage during menses. On histopathology,the
incision of focus looks grey or slightly yellowish; the
microstructure is composed of endometrium, endometrial gland
or endometrial gland-like structure with bleeding.
majority of cases, it follows surgery on the uterus. The
commonest surgery prior to scar endometriosis is caesarian
section. Surgical scar endometriosis following
section has an incidence of 0.03%–0.4%17.Abdominal
endometriosis has also known to follow tubal
ligation,hysterectomy,ovarian cystectomy and diagnostic
laparoscopy,(even at trocar sites53).
it presents in women over 30 years of age, although it can
occur much earlier. The onset of symptoms may vary,
anywhere between 6 months to 10 years, but commonly it
occurs a year after surgery1,2. When the
symptoms occur many years after original surgery, the
history of previous surgery may be overlooked by the
clinician, leading to difficulties in diagnosis. The patient
usually presents with a swelling in the abdominal wall,
which increases in size or becomes more painful at the time
of menstruation. Rarely there may be any associated pain.
The lesion may even bleed during menstruation. Umbilical
endometrioma has been described in patients without any
history of surgery and without any evidence of pelvic
endometriosis,the first description being in 1886.
Usually, this type of endometriosis is associated with
pelvic pain and dysmenorrhea, even though silent umbilical
endometrioma has been described38.
Examination in cases of abdominal endometrioma may reveal
small lumps,in varying sizes, sometimes even as small as 1cm
or 2 cm. In the literature, the mean size of masses has been
3.1 (range 1.5–4.8) cm17. The differential
diagnosis of the swelling could include hernias, suture
granulomas, abscesses, malignant tumors, neuromas, and
hematomas2. Imaging studies are not absolutely
essential in diagnosis. However,
Ultrasound can help verify the depth of extension and the
consistency of the lesion. CT scan can show extent of the
lesion and whether it is acute or chronic.
resonance imaging (MRI) has also been used in evaluation of
endometriomas. Tl-weighted images may show a bright signal
if acute hemorrhage is present, and T2-weighted images will
show low signal intensity if bleeding is of a chronic nature1.
Fine needle aspiration cytology (FNAC) may be used to rule
Medical treatment has not been known to be fully successful
in curing the disease. Treatment is by wide surgical
excision of the mass as there is a slight risk of
development of malignancy2. If surgery involves
removal of fascia,a mesh may need to be placed to prevent
Role of a gynecologist:
Primary excision of the nodule may be done by the
gynaecologist. However, sometimes the gynaecologist may be
called in only after the diagnosis of endometriosis has been
made on histopathology. One has to decide whether a
laparoscopy has to be done to rule out pelvic
endometriosis. It has to be remembered that cutaneous
endometiosis may be assossiated with
endometriosis in 20±46% of cases.51 If the
diagnosis of endometriosis is made preoperatively, it may be
combine the excision procedure with an exploratory
laparotomy or laparoscopy to rule out other foci of
patient should be informed of the high rate of recurrence of
this disorder. Follow-up should be arranged for those
patients who present multiple recurrences, in order to avoid
any chance of malignant transformation36.
Pre-operative administration of GnRh analogues may reduce
the size in selected cases, where there seems to be a need
for reducing the size before surgery.
Prevention of scar endometriosis could probably be attempted
by conscious avoidance of not allowing instruments and swabs
which have touched the endometrium at the time of caesarian
section or hysterotomy from coming in contact with the
subcutaneous tissues or skin. Thorough sucking out and
washing of endometriomas before ovarian cystectomy in
chocolate cysts could also be useful in avoiding endometrial
tissues from reaching the abdominal wall. Washing the
abdominal wound with saline, before closure, in laparotomy
could be useful.
caused by migration of endometrial tissue through the
fallopian tubes into the pelvis or down the vagina into an
episiotomy scar, after a vaginal delivery, manual uterine
exploration, or postpartum curettage. It may also be caused
by a metaplasia of müllerian duct remnants which develop
into endometriotic tissue secondary to cyclical ovarian
stimulation. Depressed cell mediated immunity may favour
the implantation of endometrial tissue at ectopic sites.
with perineal endometriosis usually present with a tender
perineal nodule which lies in relation to an episiotomy scar
causing cyclic pain.
site endometriomas may also mimic anal abscess, and the
diagnosis can be thought of, when, instead of pus, the
swelling drains dark coloured chocolate material14.
Endometriosis has been reported in the anal sphincter, the
patient presenting with
of fluctuating pain in the right anterior perianal region
without any apparent swelling anywhere. An endosonogram of
the anal canal detected the lesion in the external anal
endometriosis is best treated by wide excision. When the
patient presents with a fluctuating lesion near the
perineum, sometimes simple drainage may be done thinking of
it to be an abscess. However, simple drainage will
inadvertently lead to recurrence. Use of Goserlin acetate
for 3 months preoperatively has been described by
Kang et al in a 5cm endometriotic lesion in the perineum,
which developed over 4 years after her last vaginal
delivery, involving an episiotomy14. Since
perinal endometriosis may involve vital structures like
rectum or anal sphincter, in large lesions, it may be
prudent to reduce the size of the lesion before attempting
Vaginal vault endometriosis:
Endometriosis of the vaginal vault can appear as reddish
lesions, which may bleed. When plain estrogen is given to
women with history of hysterectomy with bilateral
oophorectomy, these lesions could bleed, sometimes
profusely. Stopping estrogenic stimulus could be enough to
stop the bleeding in such cases.
vault endometriosis has been described in patients after
laparoscopic hysterectomy where a lot of morcellation had
been used. In such cases, surgical resection of the lesion
may be necessary.
Endometriosis of the Urinary Tract
with urinary symptoms may primarily visit the gynaecologist,
who should therefore be alert to possibility of
endometriosis of the urinary tract, which occurs in 1-2% of
majority (84–90 per cent) of urinary tract endometriosis
affect the bladder and the lesion is generally located
behind the trigone or on the bladder dome. There are two
forms of bladder endometriosis: isolated or associated with
peritoneal endometriosis. The former seems to appear after
iatrogenic dissemination of endometrial cells after surgery
(caesarean section, hysterectomy or dilatation and
curettage). In the latter, the bladder lesion is a
manifestation a generalized pelvic disease. Diagnosis:
may present with cyclical dysuria ,abdominal pain or
increased urinary frequency with or without haematuria.
There is usually a delay in diagnosis of the disease, and
the patient may undergo many different types of therapy
like repeated antibiotics, anticholoinergic drugs or even
benzodiazepines. Clinical symptoms generally peak 1 week
before and after menstruation, and in more than 70 per cent
of the cases they are identical to those of interstitial
Ultrasonography may show a mass in front of the vagina. A
cleavage plane may be found between the lesion and the
detrusor muscle. Cystoscopy may show a bulge into the
bladder wall or a bluish lesion . Sometimes, the bluish
lesions may not be visible,leaading to false negative
cystoscopy. The lesion may not be visible laparoscopically,
although laparoscopy can rule out concomitant pelvic
endometriosis is amenable to medical therapies, but the
symptoms usually recur on stopping treatment. However,
response to hormonal therapy and recurrence on stopping
treatment may help clinch the diagnosis in difficult to
diagnose cases. In post menopausal bladder endometriosis,
long lasting cure could be expected, as the oestrogenic
milieu is no longer there near the lesion.
Surgical treatment should involve total excision of
disease, which may mean a partial cystectomy. The cystocopic
route is generally contraindicated because of the risk of
perforation or short-term recurrence due to incomplete
excision. Laparotomy tends to be the treatment of choice,
especially in cases of multifocal lesions. Laparoscopy has
a disadvantage that it will not allow palpation of the
Ureteric endometriosis as sole manifestation of the disease
was first described in the literature in 195648.
is rare and may result in a high rate of renal loss before
it is recognized.
is most commonly affected in the distal third.
It may be extrinsic in 70-80% of cases, causing progressive
stenosis of the ureter.
The intrinsic form subverts the
muscular layer or the ureteral mucosa, always also involving
the adventitial coat and periureteral tissues.
endometriosis may present with hydronephrosis, caused by
back pressure to the kidneys or anuria if there is bilateral
involvement. USG is useful to look for hydronephrosis.
Intra Venous Urography can detect status of ureteric
Management is by ureterolysis with excision of endometrial
tissue and laparoscopic partial resection of the ureter with
uretero-ureterostomy or neo-cystostomy. Medical therapy
is generally not successful.
Endometriosis affects the intestinal tract in 3% to 37% of
all patients with pelvic endometriosis.
sites include the sigmoid colon and rectum (85%), small
bowel (7%), caecum (3.6%) and appendix (3%). The incidence
is highest in the
sigmoid and rectum, because they are the most dependent
portions of the bowel, as well as being directly adjacent to
the gynecologic organs.22
incidence of mucosal and submucosal involvement by
intestinal endometriosis is estimated to be only 30% and
66%, respectively, making preoperative diagnosis of
intestinal endometriosis a difficult proposition.
majority of small bowel involvement occurs in the distal
ileum, especially the last l0cm ofthe terminal ileum16.
Patients may remain asymptomatic. They may also present
with chronic symptoms, or symptoms of acute intestinal
obstruction. Episodes of obstructive symptoms will occur
close to the menstrual period. The cause of the bowel
obstruction could be either endometrial tissue causing an
intusception or volvulus, or, a fibrotic stricture in the
bowel wall. The latter is due to release of fibrogenic
ferrous material from degraded blood, occurring at each
menstruation from ectopic endometrial tissue. The white
cell count may sometimes be elevated, making diagnosis
difficult. When they present with obstruction or
intussusseption, generally, resection anastomosis becomes
necessary and the diagnosis is then made on the
histopathology of the specimen.
first described endometriosis involving the appendix, in
1921, with the documented frequency of appendiceal
involvement in patients with endometriosis ranging from less
than 1 to 5.3%2 and the frequency of
endometriosis of appendicectomy specimens ranging from 0.05
to 0.80%4 . The appendix is estimated to be
involved by microscopic endometriosis in >10%
patients with ovarian endometriomas .
Diagnosis; Patients with isolated appendicular endometriosis
may remain asymptomatic or present with acute abdominal
pain, a palpable mass in the lower abdomen or chronic
recurrent bouts of abdominal pain associated with vomiting
and diarrhoea.. It is generally asymptomatic, and found as
an incidental finding at laparotomy. Endometriosis of the
appendix may also present as acute appendicitis, intestinal
obstruction resulting from intussusception of the appendix
or lower gastrointestinal bleeding.
may present with rectal bleeding with evidence of mass in
the intestine, on CT scan,at the site of endometriosis;.
Perforation of the sigmoid colon due to endometriosis has
been reported in a 28 year old woman during pregnancy46.
Diagnosis is usually made on the histopathology of the
endometriois can present with cyclical rectal bleeding,
diarrhea, with or without abdominal pain. Biopsy of the
endometriotic area may not always yield a diagnosis because
the endometrial tissue rarely infiltrates the mucosa.
Medical treatment could be tried, but if it fails surgical
treatment is by resection anastomosis of the rectum. This
can be done laparoscopically or by laparotomy. Transanal
endoscopic microsurgery has been described for indicated for
small lesions (<1 cm) 34.
Endometriosis is known to affect the lung in it’s
parenchyma, as well as in the pleura54. Thus in
any patient coming with cyclic respiratory symptoms like
cough, dyspnea etc, the possibility of lung endometriosis
should be thought of ,
Both pleural and
parenchymal lesions are found more often on the right side
than the left.
patients with pleural endometriosis also have pelvic
endometriosis. In contrast, parenchymal endometriosis
usually occurs in women without co-existing pelvic disease
and is believed to arise from embolism of endometrial tissue
from the uterus to the lungs via the pulmonary arteries.
Parenchymal endometriosis occurs more frequently in the
lower lobes, where blood perfusion is greatest.
pneumothorax is the commonest manifestation of pleural
endometriosis. Catamenial pneumothorax is recurrent
pneumothorax that occurs within 72 hours of menstruation.
Three distinct mechanisms have been proposed for the
assossiation of spontaneous pneumothorax and the menstrual
period based on metastatic, hormonal, and anatomical models7,6,.
Metastatic model: The metastatic model suggests migration
of endometrial tissue via the peritoneal cavity through
transdiaphragmatic lymphatic/ hematogenous routes or
through diaphragmatic fenestrations into the pleural space.
Because these congenital diaphragmatic channels or
fenestrations are more common in the right hemidiaphragm,
manifestations of thoracic endometriosis occur predominantly
on the right side of the chest. Alternatively, it is
postulated that endometrial tissue may be deposited in the
chest cavity during embryonal development. Monthly shedding
of endometrial tissue is believed to result in pleural
irritation that causes chest pain and pulmonary air leaks,
resulting in pneumothorax. This theory is supported by the
identification of endometrial deposits in the pleural space,
present in 13% to 62.5% of these patients.
Hormonal model: The hormonal hypothesis proposed by Rossi
and Goplerud in 1974 suggests that high serum levels of
prostaglandin F2 at ovulation may lead to vasospasm and
associated ischemia in the lungs. They speculated that this
tissue injury, combined with prostaglandin-induced
bronchospasm, may result in alveolar rupture and
pneumothorax. However, since Non Steroidal Anti Inflammatory
agents are not effective in this condition, this theory has
fallen out of favour.
Anatomic model: The anatomical model is based on the influx
of air into the pleural space from the peritoneal cavity via
diaphragmatic fenestrations. This model postulates that
during menstruation, there is a loss of the cervical mucus
plug . This allows, air to enter into the peritoneal
cavity via patent fallopian tube(s) and subsequently into
the pleural space via communication through the diaphragm.
Parenchymal endometriosis : Vessels in the lung filter blood
for exchange of gases. Park33 postulated that
during this process, endometrium which may have travelled in
the blood may be trapped by the lung vasculaure.
Endometium may have reached the blood following a curettage
or caesarean section33.
presentations and management of Thoracic endometriosis:
endometriosis syndrome could present as Catamenial
pneumothorax, catamenial haemothorax, catamenial haemoptysis
and lung nodules.
Catamenial pneumothorax: It is a very rare disease affecting
women between 30 and 40 years of age.
common symptoms of catamenial pneumothorax are right sided
pleuritic pain and dyspnea. Pneumothorax is diagnosed by
noting appropriate physical findings (i.e.,
diminished/absent breath sounds on the affected side) and
documenting the presence of pneumothorax on chest
radiograph. However, pneumothorax may not recur at every
menstrual cycle, and is not always associated with pelvic
endometriosis. Additional investigations like CT or MRI
and may show diaphragmatic or pleural thickening in affected
lung areas. Endometriomas appear as hypodense nodules on
CT scan if they are larger than 1 cm, whereas a homogeneous
hypersignal is seen on MRI.
currently two modalities to treat catamenial
pneumothorax—hormonal and surgical.
treatment modalities include the use of OC pills, danazol,
progestational agents, and gonadotropin-releasing hormone
(GnRH) analogs. The optimal length of treatment has not been
clearly defined but is
successful suppression of recurrence of the pneumothorax. In
most studies, treatment is
Implemented for a minimum of 6 months. However, hormonal
therapy alone, is not sufficient to control symptoms in a
majority of cases.
options to treat catamenial penumothorax include, Video
Assisted Thoracoscopic Surgery (VATS) with inspection of
diaphragmatic surfaces for defects, or by thoracotomy.
Nodular blebs in the pleura are excised endoscopically or by
thoracotomy with Pleuodesis and pleural abration,and sealing
of diaphragmatic defects . Catamenial haemothorax: Chemical
opacities several centimeters in size, nodular lesions,
thin-walled cavities, cystic changes, and bullous formation54.
All of these lesions may vary in size during the menstrual
cycle and may disappear after the menses. Pulmonary nodules
were observed more often in older women. With increasing
age, hormonal support for the viable endometrial tissue
decreases and endometrial tissue with surrounding fibrotic
tissue may occur as a lung mass or infiltrate on a chest
Role of a
gynaecologist: A gynaecologist should be alert to the
possibility of pleural or parenchymal lung endometriosis in
patients with cyclical respiratory symptoms. She/He should
resort to investigative modalities like chest radiograph or
CT scan of the chest even though the symptoms may appear
trivial initially, as they appear only cyclically. Referral
to thoracic surgeons may be done after diagnosis. If a
thoracic surgeon calls a gynaecologist after diagnosing
endometriosis, hormonal suppressive therapy should be
instituted. Less than 1/3 of women with catamenial
pneumothorax have concurrent pelvic endometriosis55.
Routine hysterectomy with bilateral oophorectomy in these
patients may necessitate subsequent oestrogen therapy for
menopausal symptoms which could activate lung lesions41.
This should be avoided.
pleurodesis is the treatment of choice.
Catamenial haemoptysis: This is a very rare condition and
the leading clinical symptom of tracheo-brochial or
pulmonary parenchymal endometriosis33. The most
important criterion of diagnosis is the patient’s history of
catamenial symptoms. Chest X-Ray may be normal, but may, in
some cases show solitary or multiple pulmonary nodules with
cyclical changes in size. Chest CT scans are more useful and
can reveal ill-defined local infiltrates, well-defined
nodular densities and cystic lesions, which may change in
size during the menstrual cycle. The diagnostic use of
bronchoscopy is said to be limited, as most cases of
pulmonary endometriosis involve the distal pulmonary
parenchyma rather than the mucosa of the large bronchi, and
the bleeding site may only be evident during the menses .
However, Wang et al described 4 cases of bronchoscopic
biopsy and diagnosis of tracheobronchial endometriosis,
which were subsequently treated with Danazol42.
nodules: Lung nodules as a variant of parenchymal lung
endometriosis are rarer than hemoptysis.
radiographs often show normal findings, they can also reveal
solitary or multiple nodules, cystic defects and opacities
displaying cyclical changes in size. CT findings in
pulmonary endometriosis include ill-defined
Endometriosis at other sites
Endometriosis of the liver was first described in 1986.
Patients diagnosed with liver endometriosis have usually
presented with pain, with H/O endometriosis before. The
presence of space occupying lesions in the liver of unknown
eitiology should alert the physician of the possibility of
liver endometriosis. There may be subsequent ascites,portal
vein thrombosis and jaundice. Endometrial Stromal sarcoma
of the liver has been described25. Treatment is
by surgical resection. Prognosis of Endometrial Stromal
Sarcoma depends on the mitotic index of the tumour.
et al have described a case of a young girl with cyclical
right shoulder pain, responding partially to
anti-inflammatory drugs and contraceptive pills, with
concomitant pelvic endometriosis. At the time of
laparoscopy for pelvic endometriosis, two endometriotic
lesions were found on the diaphragm on the right hemi
diaphragm. They were cauterized, as they seemed far away
from the ventricles of the heart. The patient was relieved
of her symptoms.
patients with pelvic endometriosis, rotating the laparoscope
to look for lesions in the diaphragm could be useful in
symptomatic patients, complaining of cyclical shoulder
pain. Experienced laparoscopic surgeons could cauterize the
lesion after ascertaining that surrounding organs are not
Endometriosis of the Alcock’s canal56:
patients with endometriosis of the rectovaginal septum, the
inflammation surrounding the endometriotic nodule could
sometimes entrap the pudendal nerve entering the Alcock’s
canal, which is the space bound laterally by the ischium and
medially by the obturator internus aponeurosis (ischiorectal
fossa).The pudendal nerve comprises sacral roots S2, S3, and
S4, and gives rise to the perineal nerve, which innervates
anal and urethral external sphincters, and perineal and
vulvar skin in women. Pudendal nerve entrapment causes pain
in the lower central pelvic areas (anus, perineum, or
vulva). Pain can affect one, several, or all areas, and is
usually worse in the sitting position. Frequently, there is
also urinary or anal incontinence and sexual dysfunction.
with endometriosis of the alcock’s canal may present waith
sciatica like pain assossiated with menstrual periods.
Physicians should be alert to the possibility of
endometriosis when patients complain of cyclical sciatica
like pain. Symptoms can be relieved with GnRh Analogue
Endometriosis with Ascites:
Endometriosis with ascites is very rare and it presents a
diagnostic dilemma for the clinician. Only sporadic cases
have been reported. Exact cause is not known, but irritation
of the peritoneum with blood and endometrial cells,
obstruction of lymphatics in the diaphragm have all been
put forward as theories. In most of these cases, a
diagnostic laparotomy/laparoscopy and histopathologic
confirmation of the diagnosis is required. Definitive
management involves surgical removal of endometriosis
tissues followed by long-term hormonal suppression therapy.
Patients who undergo conservative surgery or medical
management need close
follow-up after stopping medical treatment because
recurrence can occur when the hormonal suppression
withdrawn. There is a rare chance for developing malignancy
as endometrioid or clear cell carcinoma,
especially in atypical endometriosis. The reported frequency
of malignant transformation is 5–10%.
Endometriosis in the inguinal region was first reported by
Cullen in 1896. Giovanni et al. reviewed 958 patients who
underwent clinical evaluation for endometriosis and reported
that the incidence of endometriosis in the inguinal region
was 0.6%20. Endometriosis in the inguinal region
is mostly associated with inguinal hernias, and tends to
predominate on the right side, probably because the sigmoid
colon partially protects the left groin. There usually is
concomitant pelvic endometriosis. The canal of Nuck, which
is a dilatation of peritoneum that accompanies the round
ligament and extends from the inguinal canal into the vulva,
is probably the the site through which pelvic endometriosis
extends into the inguinal canal. MRI is a useful diagnostic
modality in diagnosing this disease entity. Wide excision
by the inguinal route is the treatment of choice.
Concomitant laparoscopy may be necessary to rule out pelvic
Endometriosis in post menopausal women:
Endometriosis is said to be a estrogen dependent disease,
which is expected to regress after menopause. However, it
can affect 2-5% of post-menopausal women31. It
may follow hormone replacement therapy, as endometrial
lesions get activated with the estrogen therapy. This is
specially so, since standard treatment dictums warrant
bilateral salpingo-oophorectomy for complete eradication of
disease and this leads to severe post-menopausal symptoms.
Generally due to absence of uterus and lack of fear of
endometrial hyperplasia, progesterone add-back therapy is
not given. This can aggravate the stimulation of
endometriotic foci which may have developed anywhere in the
Endometriotic ovarian cysts and rectal nodules have also
been reported in post-menopausal women without any history
of hormone replacement therapy. They may present with
pelvic pain or with a mass in the abdomen. Although surgery
in the late post-menopausal period is risky due to multiple
medical complications associated with old age, surgical
therapy may be the only solution for such patients.
destined to proliferate and shed from the uterus has been
recorded to have reached almost all organs of the body.
Thus endometriosis can occur in almost any organ of the
body. Cyclical symptoms occurring in a woman should alert
the physician to the possibility of endometriosis. Symptoms
occurring in distant organs like the lungs or small
intestine or cutaneous endometriosis may lead the patient to
visit specialists concerned with those organs. However, a
gynaecologist may be called in to perform hysterectomy or
supervise hormone therapy, with which the non-gynaecologist
may not be familiar.
often women are more comfortable visiting gynaecologists as
primary physicians, when difficult situations arise, as they
have a bonding with them through deliveries or subsequent
illnesses. In these instances, gynaecologists who are
faced with cyclical symptoms occurring in other organs
should be alert to the possibility of endometriosis in rare
places, and should be aware of the treatment possibilities
of endometriosis occurring in these organs, to guide the
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