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the presence of endometrial tissue outside the endometrial cavity. These ectopic deposits of endometrium may be found in the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas (Figure 1) . Rarely, extrapelvic deposits of endometrial tissue are found.
is associated with infertility because of adhesions that distort the pelvic anatomy and cause impaired ovum release and pickup. However, tubal distortion is not the only cause of infertility, because patients with endometriosis seem to have poor ovarian reserve with low oocyte and embryo quality.
La lateralización el cervix es causada por el compromiso asimétrico de un ligamento uterosacro. Cervix estonotico os < 5 mm, aumenta la menstruación retrogada
accompanied by histologic confirmation of the presence of at least two of the following features: hemosiderin-laden macrophages or endometrial epithelium, glands, or stroma.15
Estrógenos estimulan el crecimiento y la función de la endometriosis. La intervención hormonal que suprime la producción de estrógenos (analógos de la gnrh) o bloquean su acción (acos, progestinas, danazol) efectivas en el tratamiento del DPC
EA: oleadas de calor. Perdida mineral osea
Derivado de la testosterona, moderada actividad por los receptores de andrógenos. El increnmento de la acción androgénica (antiestrógeno) y la disminución de la acción de los estrógenos causa atrofia. In randomized clinical trials, danazol and the GnRH-agonists reduce pelvic pain in approximately 85% of women with endometriosis, but the side e.ects of the two treatments are di.erent. The side e.ects of danazol are weight gain (mean of 4 kg at a danazol dose of 800 mg daily), muscle cramps, decrease in breast size, oily skin, and hirsutism . The side e.ects of the GnRHagonists are associated with hypoestrogenism: vasomotor symptoms, insomnia, decreased libido, headaches, vaginal dryness, and decreased bone density. Many of the side e.ects of danazol are dose dependent. Danazol at doses of 50, 100, and 200 mg daily can be e.ective in relieving pelvic pain . However, doses of danazol of less than 400 mg daily do not reliably suppress ovulation and may result in pregnancy. Danazol crosses the placenta and is a known teratogen, causing masculinization in female fetuses. The clinician must ensure that a pregnancy does not occur if low doses of danazol are being used.
Destruccion de 2 cm del nervio uterosacro cerca de la union del utero. Neurectomia presacra: interrupcion de la inervación simpática del útero a nivel del plexo hipogástrico superior decreases pain (online Table B). 30,31 Presacral neurectomy, a procedure in which the sympathetic nerves from the uterus are divided, may decrease midline abdominal pain.31 Laparoscopic surgery with ablation of endometrial deposits also may increase fertility in women with endometriosis.32 No systematic reviews or meta-analyses have compared laparoscopic drainage and laparoscopic cystectomy for the treatment of ovarian endometriomas. One RCT found cystectomy to be superior to drainage in pain relief at two years.33 intrauterine Gonadotropin-releasing hormone analogues (e.g., goserelin [Zoladex], leuprolide [Lupron], triptorelin [Trelstar Depot])
For women who present with chronic pelvic pain presumably originating from the uterus (eg, dysmenorrhea, chronic endometritis, adenomyosis), hysterectomy with or without oophorectomy may be performed laparoscopically. Chronic pelvic pain unresponsive to medical management often leads to surgical intervention including hysterectomy. In the United States, of the 590,000 hysterectomies performed each year, 10% have chronic pelvic pain as the primary preoperative indication for the surgery [4,6,55] . Although hysterectomy is most often successful in relieving complaints associated with pathology (eg, fibroids, endometriosis), it may have the highest failure rates in patients with chronic pelvic pain as an indication for surgery  . Previous reports have shown that as many as 22% of patients with chronic pelvic pain continue to have pain after hysterectomy  .
Most uterine myomas cause no symptoms [4,10] . It is estimated that only 20% to 50% of women with one myoma or more experience symptoms that can be directly attributed to the tumor itself  . Approximately 62% of women with symptomatic myomas present with multiple symptoms  . The symptoms of uterine myomas usually correlate with their location, number, size, or concomitant degenerative changes  . This article reviews the clinical manifestations of uterine myomas, as listed below.
Although dysmenorrhea may be present when menstrual flow is increased, pain as a symptom of uterine myomas is not frequent. When pain does occur, it is usually associated with torsion of the pedicle of a pedunculated myoma; cervical dilatation induced by a submucosal myoma; or red (carneous) degeneration, which is mostly associated with pregnancy  . Pain is usually acute onset in these conditions and creates a challenge to rule out other acute abdominal emergencies, such as ectopic pregnancy, adnexal torsion, appendicitis, or acute pelvic inflammatory disease. Some type of intermittent subacute to chronic type of pain may occur if there is associated adenomyosis or endometriosis, which should be included in the differential diagnosis (see Table 1 ). Rarely, myomas in the broad ligament may cause unilateral lower abdominal pain, or may cause sciatic nerve pain. Uterine myomas as large as 100 lb have been reported. These large myomas may outgrow their blood supply, leading to ischemia and necrosis with the tumor. This degeneration is usually associated with severe acute pain, which may necessitate surgical exploration.
Many women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool frequently is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings.
May cause adhesions, tubo-ovarian abscess, or pseudocysts. Women may present with pelvic pain, tender pelvic mass, abnormal uterine bleeding. History and pelvic examination, cervical cultures, transvaginal ultrasound, laparoscopy or laparotomy.
In patients where adhesions are a suspected cause of chronic pain, surgical exploration is the only way to confirm their presence. Laparoscopy has become the least invasive way of diagnosing the presence of adhesions. The authors favor laparoscopy for lysis of adhesions primarily because of the faster recovery and the diminished overall tissue trauma, which may lessen the risk of reformation of adhesions or de novo central sensitization  . The goal is to restore normal pelvic anatomy. Every attempt should be made to identify avascular planes and bluntly develop small vascular pedicles that can be cauterized and divided quickly; minimizing coagulum and bleeding raw areas diminishes the likelihood of recurrent adhesion formation.
Most ovarian cysts are benign and are rarely associated with chronic pelvic pain. Although ovarian cysts, such as hemorrhagic cysts and follicular cysts, are often asymptomatic, when they cause pain the pain is usually acute and resolves spontaneously within one or two cycles. Sometimes acute pain is so intense that it requires immediate surgical intervention as in the case of ovarian torsion or intraperitoneal hemorrhage. In rare cases cysts may cause recurrent or chronic pelvic pain [1,40] , but data are lacking on laparoscopic treatment of ovarian cysts for relief of chronic pelvic pain  . The exception is ovarian endometriomas: complete laparoscopic resection (cystectomy) leads to a significant decrease in recurrence and pain compared with drainage or cautery of the cyst lining
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