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1. Etiology：
(1) Retrograde menstruation: the most popular theory
(2) Metaplasia
(3) Lymphatic and vascular metaplasia: can helps to explain rare and remote sites of endometriosis ( as well as multiple lesions in the lung).
(4) Iatrogenic dissemination:
(5) Immunologic defects: it is not yet established whether endometriosis is a related to immunologic problem.
(6) Genetic predisposition: the risk of endometriosis is seven times greater if a first-degree relative has been affected by endometriosis.

2. Pathology
(1) The majority of endometrial implants are located in the dependent portions of the female pelvic.
common sites: ovaries, pelvic peritoneum, ligaments of the uterus, sigmoid colon, pelvic lymph nodes, appendix, cervix, vaginal fallopian tubes.
(2) Gross pathologic changes of endometriosis exhibit wide variability in color, shape, size, and associated inflammatory and fibrotic changes. The color of the lesion varies widely and may be red, brown, black, white, or yellow or a pink, clear, or red vesicle. New lesions are small, sometimes blood filled cysts that are less than 1 cm in diameter. The older lesions have more intense scarring and are usually puckered or retracted from the surrounding tissue.
(3) The three cardinal histologic features of endometriosis are ectopic endometrial glands. Ectopic endometrial stroma, and hemorrhagic into the adjacent tissue.

3. Clinical diagnosis
(1) Symptoms
=>The classic symptoms of endometriosis are cyclic pelvic pain and infertility. The chronic pelvic pain usually presents as secondary dysmenorrhea and/or dyspareunia. Approximately one third of patients with endometriosis are symptomatic.
=> No correlation between the anatomic stage of the disease and the patient's perception of severity of pelvic pain.
=> Increased incidence of first trimester abortion.
=> Approximately 15% of women with endometriosis have coincidental anovulation.
=> Less common symptoms: cyclic abdominal pain, intermittent constipation, diarrhea, dyschezia, catamenial hemothrax, bloody pleural fluid.
(2) Signs
=>The most prominent pelvic finding of endometriosis is a fixed retroverted uterus with scarring and tenderness posterior to the uterus.
=>Ultrasound examination shows no specific pattern for pelvic endometriosis. Therefore pelvic ultrasound may give additional and confirmatory information, but cannot be used for primary screening.
Sonagraphy findings of endometrioma:
echogenic homogenous cystic mass: most common
Multiple lobular cystic mass
Heterogenic cystic mass
Cystic with local echogenic mass

4. Natural History
(1) The rate of progression of the disease varies widely from one patient to another. Serial pelvic examinations are a poor indicator of progression of the disease. The natural history of the disease is largely speculation.
(2) CA-125 levels are elevated in most patients with endometriosis and increase incrementally with advanced stages. However, assays for serum levels of CA-125 have a low specificity, physicians may only be able to follow the course of persistent or recurrent disease or predict the success of therapy by measuring serial CA-125 levels.
(3) Approximately 10% of teenagers who develop endometriosis have associated congenital outflow obstruction.

5. Management
The appropriate treatment for endometriosis varies widely because of the spectrum of clinical symptoms and vast differences in extent of the disease from one patient to another. Therefore the treatment plan must be individualized. Choice of therapy depends on multiple variables, including the patient's age, her future reproductive plans, the location and extent of her disease, her symptoms, and associated pelvic pathology.

6. Medical Therapy
The primary goal of the hormone treatment of endometriosis is induction of amenorrhea.
To date no hormonal therapy has been able to produce long-lasting cures with ablation of all foci of endometriosis after discontinuation of hormonal management.
(1) Danazol
=>Danazol is a synthetic steroid derivative of ethisterone (17-à-ethinyltestosterone). The half-life of this oral drug is between 4 and 5 hours. It is metabolized in the liver with cleavage of the isoxazol ring, women who take danazol for longer than 6 months should have serum liver enzyme determinations.
=>The drug is mildly androgenic and anabolic. Many of danazol's side effects are directly related to these two properties. Danazol binds to androgen and progesterone receptors and also binds to sex hormone- binding globulin. The latter effect results in a three-fold increase in endogenous free testosterone levels.
=>It can significantly decreases FSH and LH levels by a dose of 800 mg a day. Dosages of 800 mg daily produce amenorrhea and inhibition of ovulation within 4 to 6 weeks after onset of therapy. The drug is started on the fifth day after the onset of menses. The lower dosages of danazol are not as effective at producing amenorrhea and anovulation.
=>Side effects related to danazol therapy include menopausal hot flushes, atrophic vaginitis, emotional lability, weight gain averaging 8 to 10 pounds, fluid retention, migraine headaches, dizziness, fatigue, depression, oily skin, facial hair, and eepening of voice, decreases HDL levels and elevates LDL levels.
=>The uncorrected fertility rate following danazol therapy is approximately 40%, 5% to 30% of patients will have recurrence of symptoms within 2 years following therapy.
No significant differences between the efficacies of danazol and GnRHa.
(2) GnRH Agonists
=>GnRH agonists are 10 to 200 times more potent and have much longer half-lives than the natural hormone, induce protracted periods of downward regulation. These agonists may be administered by intravenous, intramuscular, subcutaneous, intravaginal, or intranasal routes.
=>GnRH agonists have no effect on sex hormone-binding globulin. Thus the androgenic side effects from danazol caused by the increase in free serum testosterone are not observed, and no significant changes occur in total serum cholesterol, HDLs, or LDLs during therapeutic periods as long as 6 months. The side effects are primarily those associated with estrogen deprivation, similar to menopause. The three most common symptoms are hot flushes, vaginal dryness, and insomnia. The decrease in bone density is partly or completely reversible after discontinuing therapy.
=>After 6 months of GnRH agonists therapy, ovarian function will return to normal in 6 to 12 weeks. Endometriomas and severe adhesive disease have not responded to hormonal therapy. The primary advantage of GnRH agonists over danazol is better patient compliance.

7. Oral Contraceptives
(1) The present low-estrogen combination pills, specifically the ones with a relatively high progestin potency, are equally effective. The regimen is aimed to maintain their amenorrhea on a comparatively low dosage of steroids. It is important to emphasize to the patient the goal of continuous rather than intermittent oral contraceptive therapy.
(2) The many side effects of inducing amenorrhea with oral contraceptives include weight gain, breast tenderness, nausea, chloasma, an increase in appetite, irritability, depression, edema, hypertension, and vaginal discharge.
(3) The results of continuous oral contraceptive therapy include a decrease in symptomatology in approximately 80% of patients during therapy and an uncorrected pregnancy rate of about 30 % after therapy.

8. Surgical Therapy
The choice between medical treatment to suppress endometriosis and surgical therapy to remove it depends on the patient's age, symptoms, and reproductive desires.
(1) Laparoscopy is employed frequently for diagnostic reasons and can also be used therapeutically. Conservative surgery has as its goal the removal of all macroscopic, visible areas of endometriosis with preservation of ovarian function, adhesionlysis to restore normal anatomy. Definitive surgical treatment is reserved for patients with far-advanced disease and for whom future fertility is not a consideration. Definitive surgery involves total hysterectomy, BSO, and the remove of all visible endometriosis.
(2) Classification system of endometriosis:
AFS(American fertility society )system:
This system reflects the extent of endometrial disease, but it is not based on the correlation of pain or infertility .

(3) The pregnancy rate after laparosopy treatment :
Treatment of moderate disease has an approximate 60% pregnancy success rate, severe disease has pregnancy success rate of 35%. Surgical management of infertile women with minimal to mild endometriosis is controversial .

9. Recurrence rate after treatment:
(1) Operation: recurrence rate is about 5-20% per year a cumulative rate of 40% after 5 years
(2) GnRHa: minimal disease: 37% (five years after therapy)
Severe disease: 74% (five years after therapy)
(3) Danazol: similar to GnRHa.