Endometriosis

Endometriosis is a disease in which some parts of the endometrium can be found outside the uterine cavity. Symptoms include painful menstrual bleeding, prolonged pain in the lower abdomen, painful sexual intercourse, and fertility problems. Endometriosis is the most frequent gynecological disorder during a female reproductive age. It is seen in 20 - 50% of infertile women and in 50% of women with pelvic pain.

The cause of endometriosis

The cause of endometriosis has yet to be determined. Several factors usually contribute to the formation of endometriosis – genetic, immunologic, and hormonal.

Under normal circumstances, hormonally changed endometrium flushes out from the uterine cavity during menstrual bleeding. Small parts of the endometrium are then passed through the fallopian tubes to the abdominal cavity. One of the theories assessing the formation of endometriosis suggests that the same hormonal process that takes place in the endometrium also occurs to the nested (implanted) parts of the endometrium in the abdominal cavity and pelvis.

Another theory presumes that some cells in the abdominal cavity change into cells resembling endometrium after repeated inflammations in the woman’s small pelvis or as a reaction to the higher blood estrogen levels (female sex hormones).

Immunologic theory suggests the presence of endometrial antibodies in a female body or lower cell immunity. As a result, the woman's immune system does not react to the endometrial bearings, does not destroy them, and facilitates nesting (implantation) of the endometrium or its transition into a different cell structure (metaplasia).

Endometriosis causes infertility by creating adhesions in the woman's pelvic area, which restrict contact between the internal reproductive organs and cause changes in the hormonal, immunologic, and biochemical processes responsible for merging of embryonic cells, early embryonic development and the transport of an embryo into the uterine cavity.

4 basic types of endometriosis

1. Peritoneal endometriosis – ectopic tissue in the pelvis.

Colored stains several millimeters in size are usually found on the perineum during laparoscopy. Color of the stains differs based on the stage of development of the endometrial lining. Initially, they are red in color and go through the same hormonal development as the uterine lining. This leads to a local inflammation in the area of the polyps, which close themselves as the time passes. In the closed polyps, the secreted tissue is accumulated, which makes them larger and changes its color to blue. Vascular supply in the polyps gradually disappears, and they transform into scars. This leads to the final stage – white endometriosis. The scarring process in the area near the fibroids can sometimes form round defects (openings) on the peritoneum.

2. Ovarian endometriosis – fibroids on the ovaries.

This type is characterized by colored fibroids on the surface of the ovaries, which can nest themselves deep down in the ovary and form a cyst up to a few centimeters in size. The cyst is known as the endometrium or an endometrial cyst. It contains brownish liquid, which is why it is often referred to as a tar or chocolate cyst.

3. Endometriosis of the rectovaginal septum – endometriosis at the thin structure separating the vagina and the rectum.

The presence of tough nodules is typical for this type of endometriosis. Nodules are formed by excessive production of smooth muscle fibers and ligaments in the area near the endometrial glands. This type is also frequently referred to as deep endometriosis because it affects not only the septum mentioned above but also the ligaments between the uterus and the pelvic bones. Nodules can also form in the muscles of the pelvic organs. This endometriosis is only minimally affected by changes during the menstrual cycle, and it is manifested by significant and prolonged pain.

4. Adenomyosis – adhesions inside the uterine muscles.

This type usually does not occur as an isolated manifestation. Often, it is combined with peritoneal endometriosis, often uterine myomas - muscular nodules on the uterus. Symptoms include increased bleeding, enlarged and painful uterus, and some additional symptoms typical for endometriosis, such as painful menstruation, pelvic pain, and pain during sexual intercourse.

Diagnosis of endometriosis can be determined based on the analysis of the patient’s subjective problems or by clinical examination combined with ultrasound imaging. However, the diagnosis is most often determined only after laparoscopy.

Treatment of endometriosis

• Conservative – hormonal treatment

The success of this treatment is high (75-95%). However, the difficulties may recur within one year after discontinuing the treatment in 25-50% of patients. Susceptibility to treatment is individual and depends to a large extent on laparoscopic and histological findings. The greatest success can be achieved with peritoneal deposits (on the peritoneum). Hormonal treatment in ovarian endometriosis is less successful, and in the rectovaginal septal defect (between the vagina and rectum), it is mostly ineffective.

The medications used in the treatment block the hormones of the controlling hormonal center –pituitary gland – hypophysis. The level of ovarian hormones, estrogens, is reduced thanks to the effect of the medications, stopping the regular endometrium transformation. Thanks to the treatment, the endometrial foci shrink and disappear. The treatment lasts 3-6 months.

The medication is mostly administered subcutaneously or in the form of a simple intramuscular injection (DIPHERELINE, DECAPEPTYL, ZOLADEX). Side effects of this therapy include temporary loss of menstruation, depression, mood swings, hot flashes, and sleep disorders. However, these symptoms only last for the duration of treatment.

Another type of hormonal treatment is the use of hormonal contraception, which reduces hormonal stimulation of endometrial foci. However, the treatment is less effective.

• Surgical treatment

If endometriosis is detected during laparoscopy, an important part of the treatment includes surgical removal of foci, removal of cyst (endometriomas), and disruption of adhesions. The reduction of endometrial foci ensures higher effectiveness of hormonal therapy.

If the key issue is infertility, the approach to treatment is individual. The treatment then involves assisted reproduction methods, often in combination with hormonal and surgical treatments