Endometriosis is classically defined as the presence of endometrial glands and stroma in ectopic locations. Affecting from 6% to 10% of reproductive-aged women, endometriosis may result in dysmenorrhea, dyspareunia, chronic pelvic pain, and/or subfertility. The prevalence of this condition in women experiencing pain, infertility, or both is as high as 50%. Endometriosis is a debilitating condition, posing quality-of-life issues for the individual patient. The disorder represents a major cause of gynecologic hospitalization in the United States, estimated to have exceeded $3 billion in inpatient health care costs in 2004 alone. The significant individual and public health concerns associated with endometriosis underscore the importance of understanding its pathogenesis. The first recorded description of pathology consistent with endometriosis was provided by Shroen in 1690. Despite the passage of time and extensive investigation, the exact pathogenesis of this enigmatic disorder remains unknown.

THEORIES REGARDING PATHOGENESIS

Numerous theories detailing the development of endometriosis have been described. For purposes of review, these theories can generally be classified into those that propose that implants arise from tissues other than the endometrium and those that propose that implants arise from uterine endometrium (Table 10.1.1).

Nonendometrial Origin

Metaplasia of coelomic epithelium represents a distinct pathogenic mechanism for the establishment of endometriotic implants.

The introduction of the laparoscopic approach for the management of intramural and subserosal uterine myomas has to a great extent revolutionized the modern management of myomas. Previously the only way to remove intramural and subserous myomas was by laparotomy, a procedure associated with significant postoperative morbidity. Therefore, physicians traditionally reserved abdominal myomectomy for a selected group of women where the risks and discomfort involved with laparotomy were judged worthy of the potential to preserve and enhance their fertility. Studies published in 1999 confirmed the advantages of laparoscopic myomectomy, such as the low morbidity and rapid recovery, which has led to the growing application of the technique towards women with symptomatic uterine myoma. However, laparoscopic operation is also associated with potential disadvantages including prolonged anesthesia, increased blood loss and possibly postoperative adhesion formation. This has led to a renewed interest in regard to the precise indications for performing laparoscopic myomectomy.

Indications

The primary reason for performing myomectomy in women of reproductive age is the preservation of the uterus for the purpose of childbearing. However, an increasing number of women currently elect to undergo laparoscopic removal of myomas, due to various symptoms associated with a rapidly growing or bulky uterus. In addition, some women resort to laparoscopic myomectomy when fibroids that are associated with heavy menstrual bleeding cannot be removed hysteroscopically.