Endometriosis is a disease characterized by the presence of uterine tissue in regions of the body other than the uterus, usually in the pelvis, ovaries or intestines.
Endometriosis is benign (not cancer), which, however, can be very debilitating because often associated with chronic pain and infertility.
Endometrium is a thin membrane covering the inner layer of the uterus. During the menstrual cycle the endometrium undergoes transformations induced by hormonal changes, growing into a tissue rich in blood vessels. The endometrium grows to be able to receive and nourish the embryo during pregnancy. When the cycle ends and the egg has not been fertilized, the thick wall of the endometrium breaks down and is expelled from the womb. This process is called menstruation.
Endometriosis is a disease characterized by the appearance of pieces of endometrial tissue outside the uterine lining. Endometriosis can affect the bladder, intestines, appendix, vagina, urethra and pelvis, rarely distant organs such as the lungs and central nervous system. It can also arise from endometrial tissue in surgical scars of the abdomen and pelvis. The most common locations where endometriosis occurs are presented below in decreasing order:
Uterus
Ovaries
Regions around the uterus including the Pouch of Douglas and uterine ligaments
The outer portion of the uterus
Fallopian tubes
The end regions of the intestine
Endometriosis can affect more than one location simultaneously, may coexist in 3 or 4 different organs.
This local endometrium reacts atypically to hormonal stimuli of menstrual cycle exactly as the endometrium in the uterus, i.e. it undergoes proliferation and then bleeds, causing irritation in the short term and fibrosis of the tissues around in the long term. This feature is responsible for the main symptoms of endometriosis will be discussed later on.
The cause of endometriosis is still not fully known. It is estimated that up to 10% of women have the disease. About 80% of cases of chronic pelvic pain in women are caused by endometriosis. The most affected age group is between 25-35 years.
Depending on where endometriosis occurs, the patient may present with a clinical picture ranging from no symptoms to constant and uninterrupted pain. However, the most common symptom of endometriosis is pain associated with the menstrual period, because, as has been mentioned above, as well as the normal endometrium within the uterus, endometrial tissue outside this piece also bleeds at the end of the menstrual cycle. Endometriosis is a common cause of secondary dysmenorrhoea.
If endometriosis is located in the bladder, there may be blood in the urine, if in the intestines there may be blood in the stool. The presence of endometriosis in the abdominal cavity or pelvis means there is bleeding for these cavities, causing inflammation and intense pain.
Endometriosis is also closely associated with infertility because the ovaries are one of the most frequently perpetrated, causing chronic inflammation, scarring and adhesions of the ovaries and fallopian tubes. Endometriosis affects the outside of the uterus, which also leads to deformities in the same areas and pelvis, making it unable to lead to gynecological pregnancy.
Endometriosis is not a cancer, but when it affects the ovaries, it seems to increase the risk of ovarian cancer. Interestingly the use of contraceptive pills appears to reduce this risk.
In many women the clinical cyclic pelvic pain is highly suggestive but not sufficient to establish the diagnosis. Imaging and ultrasonography can help to rule out other causes for the symptoms, such as tumors, but also rarely able to make the diagnosis of endometriosis. To be sure of the diagnosis one must look directly into the pelvis / abdomen, which is possible only through laparoscopy, a surgical procedure.
Treatment usually begins with pain medications, the most commonly used are anti-inflammatory drugs. These remedies are only symptomatic and do not act directly on the disease. The use of oral contraceptives helps to control the menstrual cycle and reduces bleeding and consequently pain.
GnRH is a hormone that causes a temporary menopause, preventing the release of estrogen and menstruation ceases. The treatment reduces pain in 80% of patients and helps to decrease the size of endometriosis. This drug can be used for up to 12 months.
Surgery is indicated in cases of severe pain, heavy bleeding, infertility or lack of response to medical treatment. The operation aims at the removal of endometrial tissue fibrosis and / adhesions that may already exist. Currently, surgery most commonly used is laparoscopy.
In many severe cases, multiple endometrial implants may be required for removal of the entire uterus and/or ovaries.
