Endometriosis

Endometriosis is a gynecological medical condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity, most commonly on the membrane which lines the abdominal cavity. The uterine cavity is lined with endometrial cells, which are under the influence of female hormones. Endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle.  Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 6–10% of women.

Symptoms

Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.

There is no cure for endometriosis, but it can be treated in a variety of ways, including pain medication, hormonal treatments, and surgery.

A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a woman feels correlates poorly with the extent or stage (1 through 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while other women may have severe pain even though they have only a few small areas of endometriosis.

Symptoms of endometriosis-related pain may include:

  • dyspareunia – painful sex
  • dysuria – urinary urgency, frequency, and sometimes painful voiding
  • dysmenorrhea – painful, sometimes disabling cramps during menses; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
  • chronic pelvic pain – typically accompanied by lower back pain or abdominal pain

Throbbing, gnawing, and dragging pain to the legs are reported more commonly by women with endometriosis. Compared with women with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas and pain intensity appears to be unrelated to the surgical diagnosis, and the area of pain unrelated to area of endometriosis.

Other symptoms include constipation and chronic fatigue.

In addition to pain during menstruation, the pain of endometriosis can occur at other times of the month. There can be pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity, pain during bowel movements and urination, during general bodily movement like exercise, pain from standing or walking, and pain with intercourse. But the most desperate pain is usually with menstruation and many women dread having their periods. Pain can also start a week before menses, during and even a week after menses, or it can be constant. There is no known cure for endometriosis.

Current research has demonstrated an association between endometriosis and certain types of cancers, notably some types of ovarian cancer, non-Hodgkin’s lymphoma and brain cancer. Despite similarities in their name and location, endometriosis bears no relationship to endometrial cancer.

Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders. A 1988 survey conducted in the US found significantly more hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma in women with endometriosis compared to the general population.

Resources

Resources

  • Painter JN et al. (2010). “Genome-wide association study identifies a locus at 7p15.2 associated with endometriosis”. Nature Genetics 43 (1): 51–54. doi:10.1038/ng.731. PMC 3019124. PMID 21151130.
  • Bulun SE, Zeitoun K, Sasano H, Simpson ER (1999). “Aromatase in aging women”. Seminars in Reproductive Endocrinology 17 (4): 349–58. doi:10.1055/s-2007-1016244. PMID 10851574.
  • Batt RE, Mitwally MF (December 2003). “Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogy”. Journal of Pediatric and Adolescent Gynecology 16 (6): 337–47. doi:10.1016/j.jpag.2003.09.008. PMID 14642954.
  • Marsh EE, Laufer MR (March 2005). “Endometriosis in premenarcheal girls who do not have an associated obstructive anomaly”. Fertility and Sterility 83 (3): 758–60. doi:10.1016/j.fertnstert.2004.08.025. PMID 15749511.
  • Van Der Linden, P. J. (1996). “Theories on the pathogenesis of endometriosis”. Human reproduction (Oxford, England). 11 Suppl 3: 53–65. PMID 9147102. edit
  • Gleicher N, el-Roeiy A, Confino E, Friberg J (July 1987). “Is endometriosis an autoimmune disease?”. Obstet Gynecol 70 (1): 115–22. PMID 3110710.

Treatments

While there is no cure for endometriosis, in many women menopause (natural or surgical) will abate the process. In patients in the reproductive years, endometriosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. In younger women with unfulfilled reproductive potential, surgical treatment attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue.

In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Further steps depend on circumstances: patients without infertility can be managed with hormonal medication that suppress the natural cycle and pain medication, while infertile patients may be treated expectantly after surgery, with fertility medication, or with IVF.

Treatments for endometriosis in women who do not wish to become pregnant include:

Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.

Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.

Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach. Recently Seasonale was FDA approved to reduce periods to 4 per year. Other OCPs have however been used like this off label for years. Continuous hormonal contraception consists of the use of combined oral contraceptive pills without the use of placebo pills, or the use of NuvaRing or the contraceptive patch without the break week. This eliminates monthly bleeding episodes.

Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.

Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in downregulation, inducing a profound hypoestrogenism by decreasing FSH and LH levels. While effective in some patients, they induce unpleasant menopausal symptoms, and over time may lead to osteoporosis. To counteract such side effects some estrogen may have to be given back (add-back therapy). These drugs can only be used for six months at a time.

Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in the woman’s body to prevent or reduce growth of endometriosis. The injection is given in 2 different doses: a 3 month course of monthly injections, each with the dosage of (11.25 mg); or a 6 month course of monthly injections, each with the dosage of (3.75 mg).

Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.

NSAIDs: Anti-inflammatory. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may be used. NSAID injections can be helpful for severe pain or if stomach pain prevents oral NSAID use.

Opioids: Morphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called “endorphins”. There are different long acting and short acting medications that can be used alone or in combination to provide appropriate pain control.

Following laparoscopic surgery women who were given Chinese herbs were reported to have comparable benefits to women with conventional drug treatments, though the journal article that reviewed this study also noted that “the two trials included in this review are of poor methodological quality so these findings must be interpreted cautiously. Better quality randomised controlled trials are needed to investigate a possible role for Chinese Herbal Medicine in the treatment of endometriosis.”

Semi-conservative therapy preserves a healthy appearing ovary, but also increases the risk of recurrence.

For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. However, strong clinical evidence showed that presacral neurectomy is more effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the pain extends to the left and right lower quadrants of the abdomen. This is because the nerves to be transected in the procedure are innervating the central or the midline region in the female pelvis. Furthermore, women who had presacral neurectomy have higher prevalence of chronic constipation not responding well to medication treatment because of the potential injury to the parasympathetic nerve in the vicinity during the procedure.

After surgical treatment of deeply infiltrating endometriosis with colorectal involvement, the endometriosis recurrence rate is estimated to be 10% (ranging between 5 and 25%).

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