Endometriosis

Endometriosis is a painful disorder where tissues that normally line the inside of the uterus (endometrium) grow outside the uterus. It most commonly affects the ovaries, intestines and pelvic tissues (the lower part of the abdomen's interior). Rarely, the tissues may spread beyond this region.

During the development of the disease, the endometrial tissues continue to act as they normally would inside the uterus, meaning they first grow, thicken, and then break down and bleed during each menstrual cycle. Since they have nowhere to exit the body, they accumulate in the organ where they have implanted. The hosting tissues become irritated, develop adhesions or scar tissue sticking organs together. All this causes pain, up to severe pain, especially during menstruation.

Symptoms and signs:

• Painful menstruation (dysmenorrhea), pelvic pain and cramps may start before and last several days into the cycle.
• Pain during or after sexual intercourse.
• Pain during bowel movements or urination, more pronounced during the menstrual cycle
• Excessive bleeding during the cycle or bleeding between cycles.
• Infertility
• Other symptoms include fatigue, diarrhea, constipation, abdominal bloating, nausea, especially during the cycle.

Causes

Endometriosis develops when one or more small areas of the abdominal lining turn into endometrial tissue. This is more likely when these cells derive from embryonic cells with the ability to take on the structure and function of endometrial cells. However, what activates this ability is still unknown. One of the explanations for the disease remains retrograde menstruation, in which menstrual blood containing endometrial cells flows back through the fallopian tubes and spreads into the pelvic cavity and beyond.

Risk factors

• one or more close relatives with the disease (mother, aunt, sister)
• menstrual cycle shorter than 27 days, with periods lasting over 8 days
• medical conditions that prevent the normal flow of menstrual blood
• past pelvic infections

Endometriosis develops several years after the onset of menstruation (menarche), temporarily subsides during pregnancy, and eases with the onset of menopause.

Complications

For pregnancy to occur, an egg released from the ovary must travel through the fallopian tube to that side, be fertilized by a sperm, go and implant in the uterus wall. Endometriosis, with its tissue reactions, can block the fallopian tubes or damage their end (fimbriae) preventing the egg from meeting the sperm, which could affect fertility. Approximately one-third to half of the women with endometriosis have difficulty becoming pregnant.

In women diagnosed with endometriosis, there is a noticeable increase in the susceptibility to some rare types of ovarian cancer.

DIAGNOSIS

Pelvic examination: during this examination, pelvic anomalies such as the presence of cysts, adhesion of surrounding organs to the uterus are looked for. However, it is often difficult to find damage, especially when small areas are affected.

Ultrasound via a transabdominal or transvaginal route show the presence of endometriotic cysts

Laboratory data: complete blood count to differentiate from pelvic infections, CA125 marker with low sensitivity, CCR1 mRNA marker with higher sensitivity.

Magnetic resonance imaging better determines the size, extent, and helps in setting the treatment strategy.

Laparoscopy is the only way to ensure the presence of endometriosis, its spread, and its treatment.

TREATMENT

Generally, conservative treatment is recommended first, followed by surgical treatment. However, everything depends on the severity of the disease, the symptoms, and the desire to have children.

For pain treatment, ibuprofen and any non-steroidal anti-inflammatory can be used

Hormonal therapy

Taking additional hormones is effective in reducing or eliminating pain

Contraceptives. (birth control pills, patch, or vaginal ring) control monthly endometrial changes, which reduces pain in mild to moderate cases.

Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists.

These medications block the production of ovarian-stimulating hormones, lower estrogen levels, leading to a reduction in endometrial implants, and disease remission during use. These medications cause a state of premature menopause, often resulting in side effects such as hot flashes, vaginal dryness, mood changes.

Danazol. blocks the production of ovarian hormones stopping menstruation, easing endometriosis symptoms. However, Danazol is not the first choice due to side effects such as acne, and facial hair growth.

Medroxyprogesterone (Depo-Provera) is in injection form, stops menstruation, and inhibits the growth of endometrial implants but has side effects such as weight gain, bone production decrease, and depressive states.

Aromatase inhibitors. the use of this class of medications helps in easing pain associated with endometriosis. Their effect is achieved by blocking the conversion of androstenedione and testosterone into estrogen, thus blocking estrogen production by endometrial implants. To reduce their effect on bone loss and folliculin, these medications should be taken in combination with GnRH agonists or estrogen-progestin contraceptives.

Hormonal treatment is not permanent as symptoms may return after stopping their use!

Surgical treatment

It can be conservative treatment aiming at removing endometriosis patches, endometriotic cysts, or internal adhesions through laparoscopy or open surgery, preserving the integrity of the reproductive apparatus.

In severe cases of endometriosis, a total hysterectomy along with the removal of the ovaries may be required.

For a woman suffering from endometriosis, it is important to find a doctor with whom she feels comfortable and at ease, but at the same time, it’s crucial to get a second opinion before starting any treatment method. If pain persists, warm water baths which provide relaxation to pelvic muscles and reduce cramps can help. Acupuncture sessions also provide relief from pain.