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Endometriosis

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What is endometriosis?

Endometriosis is a pathological condition caused by the proliferation of endometrial-like cells outside the uterine cavity. The disease can affect not only the internal genital organs, such as the uterus, ovaries, vagina but also develop outside the reproductive system – in the intestines, bladder and other organs.

Endometrial loci behave in the same way as the endometrium in the uterus – they grow and renew themselves cyclically. Clinical manifestations are varied and may depend on the location of the pathological process.

Endometriosis symptoms

  • Pelvic pain

    16-24% of patients face this problem. It can have both occasional and diffuse localization, it arises and intensifies depending on the phase of the menstrual cycle, but it can also be constant. It is often caused by inflammation and adhesions that develop at endometriosis.

  • Algodismenorrhea

    Algodismenorrhea – pain during menstruation. The most common complaint that causes suffering and discomfort above all is faced by 40-60% of women. Endometrial loci often bleed, irritating the peritoneum, causing contraction of the smooth muscles of the uterine blood supply vessels.

  • Painful sexual intercourse.

    It is observed in 2-16% of patients. With the localization of endometrial loci in the pelvic organs in the vulva, uterine-rectal space, in the region of the sacro-uterine ligaments, in the wall of the rectovaginal septum, it can cause discomfort and even pain during intercourse or when emptying the rectum and bladder.

  • Post-hemorrhagic anaemia.

    It can occur in 25-40% of patients due to significant chronic blood loss during menstruation. Weakness, pallor or yellowness of the skin and mucous membranes, dizziness, fatigue, drowsiness, irritability gradually increase.

  • Infertility.

    It is not possible to accurately assess how and why infertility occurs when affected by endometriosis. This is associated with processes in the uterine appendages at endometriosis, with changes in the functioning of the general and local immune status of the organism as a whole. 15- 56% of patients treated for endometriosis become pregnant within 6-12 months.

Endometriosis classification

  • Genital endometriosis. Affects the internal genital organs: uterus, fallopian tubes, ovaries, vagina.
  • External genital endometriosis. Only the ovaries and the pelvic peritoneum are affected.
  • Internal genital (adenomyosis or endometriosis of the uterus) endometriosis. It grows into the muscle layer, leading to an increase in the uterus body. It is often combined with uterine fibroids, while the uterus takes on a spherical shape and reaches a size up to 5-6 weeks of pregnancy.
  • Extragenital endometriosis. By this form, endometrial loci are located outside the reproductive system (digestive tract, respiratory system, urinary system, postoperative scars).
  • Mixed endometriosis. In serious and complicated cases of the disease, endometriosis can be mixed.

Depending on the depth and distribution of endometrial loci, 4 degrees are distinguished:

  • I degree – superficial and single loci;
  • I degree – superficial and single loci;
  • II degree – the loci are deeper and in greater numbers;
  • III degree – deep multiple endometrial loci, as well as endometrioid ovarian cysts, individual adhesions of the peritoneum;
  • IV degree – multiple and deep loci, large endometrioid cysts of both ovaries, extensive adhesions. The endometrium can invade the walls of the vulva and rectum. As a rule, this degree of endometriosis is difficult to treat, characterized by the large scale and degree of the process invasion.

Adenomyosis of the uterus is classified separately

– according to the depth of the pathological process invasion into the muscular layer of the uterus (myometrium):

  • Stage I – initial germination of the myometrium;
  • Stage II – endometrial loci grow to half the depth of the myometrium;
  • Stage III – the myometrium grows completely to the serous membrane of the uterus;
  • Stage IV – germination of the uterus walls with the spread of loci to the serous membrane (peritoneum).

Treatment

Due to the similarity of the course of this disease with other genital organ disorders having analogous symptoms, differential diagnostics is very important at all stages of establishing the diagnosis. The doctor carefully collects complaints and anamnesis, information about past diseases, including those of the reproductive system, surgical operations, the presence of aggravated gynaecological and obstetric anamnesis.

Further examinations are required to confirm it:

  • Pelvic ultrasound scan.
  • Computer tomography (CT) of abdominal and pelvic organs. If endometriosis of the lungs is suspected, CT of the chest organs is recommended.
  • Magnetic resonance imaging allows to determine the extent of the spread of the disease, choose the number of surgical interventions, and monitor the effectiveness of conservative treatment.
  • Hysteroscopy – examination of the uterine cavity using an endoscopic camera.

If there is an assumption of involvement of the intestines, bladder and parametrium (fibre surrounding the uterus) in the pathological process, the following can be recommended:

  • sigmoidoscopy (visual examination of the mucous membrane of the rectum using a special device – sigmoidoscope);
  • colonoscopy (examination and evaluation of the condition of the inner surface of the large intestine using an endoscope);
  • excretory urography (X-ray method of research based on the ability of the kidney to secrete radiopaque agents) and / or cystoscopy (examination of the inner surface of the bladder using a special device – a cystoscope).
  • Hysterosalpingography – a method of X-ray diagnostics of the state of the fallopian tubes and the internal cavity of the uterus, their patency and structure by injecting a contrast agent into the uterine cavity and tubes.
  • Laparoscopy with histological confirmation of the diagnosis – examination of the abdominal cavity using an endoscopic device inserted into the abdominal cavity through small incisions in the abdominal wall and histological examination of tissues. It is the most accurate method for endometriosis diagnostics.

Diagnostics

Conservative treatment is used if it is necessary to preserve the fertility function of a woman at a young age or perimenopause and at the stage of preparation for surgical treatment. When conducting drug therapy for endometriosis, treatment is carried out in two directions: elimination of pain syndrome (analgesics, non-steroidal anti-inflammatory drugs – NSAIDs) and suppression of the activity of pathological loci with the help of hormonal medications. It is important to bear in mind that conservative treatment of endometriosis without hormones is impossible
Combined oral contraceptives (COCs) or progestins are prescribed as first-line therapy.
To reduce the pain symptom, analgesics, non-steroidal anti-inflammatory drugs are prescribed.
Conducting hormonal therapy is aimed at suppressing the activity and reducing the size of endometrial loci. The selection of a treatment regimen is based on the maximum reduction in the manifestation of side effects from medications. The following are the most widely used:

  • Progestins (gestagens). They are taken during 6-8 months for any form and stage of endometriosis. Progestins favour the normalization of endometrium secretion, slow down its growth and reduce the amount of menstrual bleeding up to their complete absence. Dienogest, dydrogesterone, progesterone, norethisterone are used.
  • Monophasic COCs. Oral contraceptives completely block cyclic mechanisms in the female body, which prevents the growth and subsequent rejection of the endometrium, the development of menstrual bleeding. This leads to the complete or almost complete elimination of endometriosis manifestations.
  • Gonadotropin-releasing hormone agonists are taken once a month and are "heavy artillery" in hormone therapy. They are indicated at 3rd-4th stages of endometriosis. Their function is to block the production of specific releasing factors in the hypothalamus, which prevents further production of sex hormones according to the female cycle.

Surgery

Currently, organ-preserving surgeries, excluding resection of the uterus and its appendages, are becoming more and more preferred. This tendency is caused by the great progress in minimally invasive surgery over the past 10-15 years. The main goal of surgical treatment of endometriosis today is the removal of loci and the maximum functional recovery of the female reproductive system. It is recommended to perform excision of endometrioid lesions where possible, especially deep endometrioid lesions, laparoscopic cystectomy of endometrioid cysts (endometriomas). This allows avoiding recurrence of symptoms and endometrioma.

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