Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

12. Chronic Pelvic Pain in Women
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suggestive of endometriosis, which is subsequently encountered, then
surgical management is recommended. Typical symptoms include progressively
worsening menstrual cramps that often begin quite painfully
at menarche (dysmenorrhea), deep pain with intercourse (dyspareunia),
dyschezia (pain with bowel movements), or chronic, noncyclic pain that
occurs regardless of timing during the menstrual cycle. Endometriosis
can also contribute to infertility. Although we are focusing on reproductive-aged
women, endometriosis has been documented in many stages
of life, from premenarcheal to postmenopausal years.
Endometriosis is characteristically described as a disease that affects
peritoneal surfaces and the ovary (seen as endometrioma , or “ chocolate
cysts ”), but it also represents an inflammatory process, whereby chronic
fibrosis and infiltrating disease can occur. Sampson originally described
his theory of retrograde menstruation in the early twentieth century, but
most menstruating women will demonstrate this phenomenon [ 9 ]. It has
been suggested that women with endometriosis then have a deficiency
in their cell-mediated immune response, and foreign bodies, such as
menstrual effluent passed retrograde through the oviducts, remain untargeted
after being exposed to peritoneal surfaces [ 10 ]. Repeated exposure,
facilitated stromal infiltration, and an activated inflammatory
response result in the development of persistent lesions that can manifest
in a myriad of ways from small peritoneal blebs to peritoneal fibrosis.
Fig. 12.1. Endometriosis as peritoneal blebs in the midline posterior cul-de-sac.