A non-cancerous condition in which pieces of the endometrium grow outside the
uterus, most
commonly in the ovaries, fallopian tubes, bowel, and bladder and rarely travel
far from the pelvic region into the lung, skin and other regions of the body.
This tissue continues to respond to hormonal signals specifically estrogen from
the ovaries each month which stimulate it to grow and when estrogen level drops
the tissue bleeds after which an inflammatory process and adhesions occur. With each period we expect blood to
collect and form a chocolate cyst of ovary.
This disease affects 10-15% of premenopausal women and it is a common cause
of pelvic pain and infertility. About 35-50% of women with this disease have
difficulty in getting pregnant due to adhesions, altered prolactin release,
oocyte maturation defects, and an-ovulation.
Symptoms:
1- The most common symptom is painful menstrual cycles.
2- Dyspareunia.
3- Menorrhagia.
4- Pelvic pain and backache.
5- Painful defecation & rectal bleeding in cases of colonic endometriosis.
6- Nausea & vomiting and abdominal cramps in endometriosis of the small intestine.
7- Hematuria and frequency in endometriosis of the urinary bladder. Causes:
Causes of this disease are still unknown but some researchers believe endometriosis
to be due to an immune system problem or hormonal imbalance, others believe
endometriosis to be a genetic condition. Studies found an increased risk (5-7%) in
women with family history of this disease.
Theories of causation include :-
· Retrograde menstruation.
· Lymphatic and vascular dissemination.
· Coelomic metaplasia.
Stages of endometriosis:
We have 4 stages for this disease.
1-Microscopic endometriosis. In this stage, the peritoneum appears normal macroscopically
and lesions are identified using electron microscopy. The endometrial deposits
contain endometrial gland and stroma.
2-Early active endometriosis:-
Appears as vesicles, papules; maybe solid or fluid filled and highly vascular
and non fibrotic containing gland in the proliferative or secretory phase.
3-Advanced active endometriosis.
Present as pigmented hemorrhagic and fibrotic endometriotic deposits known as
classic lesions.
4-Healed endometriosis.
Appear as white nodules or flattened fibrotic scar containing glands only.
Risk factors:
. Japanese race.
. Family history.
. Age 30 – 44 years.
. Alcohol – caffeine intake.
. Increased peripheral fat.
Prevention:
There is no known way to prevent this disease but some believe women having
more than one child and having children early in life develop a certain level
of protection against the disease and women with long term use of birth control pills
are less likely to develop endometriosis.
Complications:
1- Infertility
2- Intestinal obstruction
3- Ureteric obstruction.
4- Secondary infection of the endometriotic lesions
5- Rupture of endometrioma.
Investigations:
1- Laparoscopy: - considered the gold standard when endometriosis is suspected.
50 % of women with pelvic pain and dysmenorrhoea have endometriosis
diagnosed at laparoscopy.
2- Ultrasonography: - have limited value in the diagnosis of endometriosis but
is helpful when there is an endometrioma.
3- MRI: - detects endometrioma, ovarian adhesions and extra peritoneal masses
and detects invasion to bowel, bladder and rectovaginal septum.
4- Blood test CA 125:- this protein increases in patients with severe endometriosis
but also increases in ovarian cancer and peritonitis. It is not a sensitive
test since it cannot detect the disease in early stages and it is not
specific, but can be used for
follow up in treated patients to check their response to treatment.
Treatment:
There is no definite cure for this disease, but several options are available.
Medical treatment
. (NSAIDS) non- steroidal anti inflammatory drugs such as ibuprofen are helpful
in reducing the severity of dysmenorrhoea.
. Combined oral contraceptive pills
Three packs of pills taken continuously are helpful in decreasing the number
and frequency of the menstrual cycles thus causing atrophy of the
endometriotic spots.
. Progestogen
Such as medroxyprogesterone given continuously will produce pseudo-decidualization
in endometriotic lesions, but has the side effects of weight gain and break
through bleeding along with the mood swings.
. Danazol
This drug has androgenic effect and is given in the dose 400-800 mg daily for
3-6 months, but it has the side effects of acne, weight gain and hirsutism.
. GnRH agonists
Present as nasal spray, subcutaneous or intramuscular injection. These drugs
cause down-regulation of pituitary function which suppresses ovarian steroid
production and induce pseudo menopause. Their side effects include hot flushes,
atrophic vaginitis and bone pain unless they are given with hormone replacement
therapy as ADD BACK THERAPY. Studies found that GnRH agonists given for endometriosis
patients undergoing in-vitro fertilization cycles improves significantly their
fertility and decreases preclinical abortions.
Surgical treatment
Aim of surgery is to relieve symptoms, restore fertility, remove endometriotic
implants and delay recurrence of the disease.
Conservative surgery done with laparoscopy is a diagnostic as well as therapeutic
procedure used to remove endometriotic lesions by laser or diathermy and adhesolysis.
This type of treatment reduces the need for open surgery in young women who
seek future pregnancies.
Radical surgery
This is reserved for cases with severe symptoms and progressive disease or women
who completed their families. Such procedure include hysterectomy and bilateral
salpingo – oophorectomy. Nearly 12% of all endometriosis patients require radical
surgery.
Endometriosis surgery is more effective in treating severe cases than mild or minimal disease.
Surgery in minimal or mild disease fails to restore normal fertility.
Assisted reproduction techniques and endometriosis:-
Endometriosis patients with long term infertility can benefit from assisted
reproduction techniques in overcoming their infertility.
Studies have shown that pretreatment with LH RH – analogues are associated with
better fertilization and implantation results especially in severe forms. Higher
IVF pregnancy rates are found when there is a six month pre-treatment using
LH RH analogues and their effects seem to be more important at ovarian than
endometrial level.
In cases of mild and moderate endometriosis with normal findings at salpingoscopy,
(GIFT) can be a useful option but some studies have noted that the results
are less
encouraging after GIFT than after IVF or ZIFT.
In endometriosis there is a risk for spontaneous abortion.
Abortion rates are 11.7 % in mild endometriosis and 13.6% in moderate forms
of the disease regardless of the stimulation protocol used.
Abortion rates of 60% in severe endometriosis cases were noted when there was
no pretreatment using LH RH agonists.
Endometriosis in menopause
Post menopausal endometriosis is one of the most unusual facets of endometriosis.
It is found in 5% of menopausal women, more often in the years immediately following
the menopause.
Clinical presentations:-
-Metrorrhagia
-Fixed and enlarged uterus raising the suspicion of endometrial cancer.
-Pelvic mass
The association of post-menopausal endometriosis and neoplasia is possible.
The transformation of an endometriotic lesion to malignancy occurs in 0.7-1%
mostly on the ovary but can also take place in the recto vaginal septum and
colon.
Causes:-
Active endometriosis
It indicates that estrogens are still being produced in the body or are supplied
exogenously as in cases of
1- Women on HRT
2- Patients taking Tamoxifen
3- Obese women in whom peripheral androgens are converted to estrogens.
4- Secretory ovarian tumors.
Hormone-independent endometriotic lesions in which the receptor level is much lower in the lesion than in the endometrium
and not influenced
by hormonal variation as the endometrium, so it gives rise to severe and extensive
clinical forms requiring hysterectomy with castration along with cyclic progestogen
for 6 months then estrogen – progestogen cyclic therapy.
fallopian tubes, bowel, and bladder and rarely travel
far from the pelvic region into the lung, skin and other regions of the body.
