Deep Endometriosis

There are three subtypes of endometriosis according to where it is located: superficial peritoneal endometriosis, cystic ovarian endometriosis (endometrioma or ‘chocolate cysts') and deep endometriosis (also referred to as deeply infiltrating endometriosis). The different types of disease may co-occur (i.e., a patient may have more than one type of disease present in her pelvis). The aim of this page is to provide information for patients about ovarian and deep endometriosis.

Ovarian endometriosis

An ovarian endometrioma is a cyst in which the wall of the cyst contains areas of endometriosis. The cyst is filled with old blood. Due to of the colour, the cysts are also referred to as ‘chocolate cysts'.
When an ovarian endometrioma is identified at laparoscopy, clinicians are recommended to surgically excise the endometrioma, as this is effective for reducing endometriosis-associated pain (ESHRE 2014 guideline).
In women with ovarian endometrioma, surgery is one of the options to enhance the chance of spontaneous pregnancy. However, surgery in women with ovarian endometrioma can result in damage to the ovary. If you have an endometrioma you should ask your doctor to discuss the surgical and medical treatment options available to you to allow you to make an informed decision about your care.

Deep Endometriosis

Deep endometriosis is endometriosis that has penetrated deeper than 5 mm under the peritoneum (the layer of tissue lining the pelvic cavity). This severe form of endometriosis may be found between the rectum and the vagina (known as recto-vaginal endometriosis), in the Pouch of Douglas, uterosacral ligaments, bowel, appendix, ureter, bladder, uterovesical fold (between the bladder and the uterus) or the pelvic wall. It can also grow into nerves such as the sciatic or obturator nerves.
Clinicians are recommended to consider performing surgical removal of deep endometriosis, as it reduces endometriosis- associated pain and improves quality of life (ESHRE 2014 guideline). This surgery is highly specialized, there is a higher rate of complications and patients and surgeons should have as much information as possible before surgery in order for the patient to give informed consent.

There is no strong evidence that surgery improves spontaneous pregnancy rates in women with deep endometriosis (ESHRE 2014 guideline).
There is one study suggesting that medical therapy (progestogens) may be effective for recto-vaginal endometriosis, reducing painful periods and non-menstrual pelvic pain as well as reducing deep pain during intercourse. (Vercellini P, 2009 ). However these studies involve small numbers of patients and there are no long term results available.

References:

Full guideline with references: Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T et al. ESHRE Guideline: Management of women with endometriosis. Hum Reprod.2014: 29(3):400-12

Patient version of the above: Information for women with endometriosis

PPSN WEB-006 v2

Issue date: February 2012
Updated: May 2015
Review date: May 2018


Photographs of some types of endometriosis including deep disease courtesy of Pr U. Ulrich, Berlin.

The following powerpoint presentation explains how pain in endometriosis is caused and suggests some possible ways of dealing with it. There are notes accompanying the slides that can be read by saving the presentation on your computer.

Pain in Endometriosis - M Platt

For patient experience of endometriosis, treatments and self-help strategies etc , see here

Resources for use during consultations and specialist centres