Endometriosis occurs with a high frequency, although the mechanism of its formation has still not been established. Therefore, treating endometriosis only alleviates its effects. What exactly is endometriosis? How is endometriosis manifested and how should it be treated?

Endometriosis - what is it?

Endometriosis(external endometriosis) is a chronic disease in which endometrial cells appear outside their proper location - that is, inside the uterus.

Outbreaksendometriosisare most often located within a woman's reproductive organs, as well as in other nearby organs - bladder, large intestine or peritoneum. In rare cases, endometrial cells can even end up in very distant places, such as in the diaphragm, skin, or lungs.

Symptoms of endometriosis

Symptoms of endometriosiscan be very different:

  • One of the earliest and most common symptoms of endometriosis is pelvic pain.This is usually the reason why patients see their doctor. Pain occurs mainly during menstruation, but can also accompany sexual intercourse (this symptom is called dyspareunia), urination or stool. Pain of greatest intensity occurs in the course of deeply infiltrating endometriosis.
  • Fociendometriosislocated around the bladder or intestines may mistakenly suggest diseases of the urinary or digestive system. It also happens that the pains caused byendometriosisradiate to the area of ​​the spine.
  • Pain is a result of both the monthly bleeding from the fociendometriosisand the inflammation they cause.
  • The inflammatory reaction, on the other hand, leads to the formation of scars and adhesions, which can further aggravate the pain. An additional mechanism of its formation is direct compression of nerves by endometrial implants.
  • Another group of disorders caused byendometriosisare changes in the course of the menstrual cycle and problems with fertility. Sometimes they are the only symptom of the disease.

Endometriosis and pregnancy

Endometriosis is thought to lead to infertility in several different ways.

First,the presence ofendometriosisin the fallopian tubes can lead to their obstruction and thus prevent fertilization. In a similar way, fertility is limited by adhesions caused by disease.

Secondly,endometriosislocated in the ovaries disturbs their proper functioning and impairs the ovulation process.

Third, the endometrium in the wrong locations can drive the immune system to "reject" this tissue. Such immune disorders may result in problems with implantation of the embryo in the uterine wall, as well as an increased frequency of miscarriages. It is estimated thatendometriosisoccurs in 35-50% of patients who have problems with getting pregnant.

Causes of endometriosis

The modern concept of the causes ofendometriosiscombines several different theories that have emerged as a result of many years of research on this disease.

Currently, it is believed that genetic, immune, hormonal and environmental factors are at the root of the disease. The individual predisposition to the development of the disease overlaps with various mechanisms causing the movement of endometrial cells or their formation in incorrect locations.

The most important concepts about the causes of developmentendometriosisinclude:

  • theories of endometrial cell movement

One of the basic and the oldest theories explaining the formation ofendometriosisis the theory of retrograde menstruation. According to it, it is believed that during menstruation, in addition to the proper excretion of exfoliated endometrium from the woman's body, there is also the so-called retrograde menstruation. This is the phenomenon of the movement of menstrual blood with the cells of the endometrium through the fallopian tubes to the peritoneum.

Endometrial cells retain the ability to survive in a new place, then multiply and thus form fociendometriosis .

Although the theory seems logical, it is definitely not a complete explanation of the whole phenomenon. It is estimated that retrograde menstruation affects up to 90 percent. menstruating women. Probably additional factors cause that some of them developendometriosison this medium (the frequency of the disease is estimated at approx. 10% of the population).

The relationshipendometriosiswith menstrual stasis is confirmed by the observation of an increased incidence of the disease in patients with outflow disorders (e.g. as a result of congenital defects of the reproductive organs).

Higher riskendometriosisalso applies to women with shortmonthly cycles (which make menstruation more frequent)

There are also theories about the possible spread of endometrial cells through blood or lymph - these may explain the formation ofendometriosisin more distant locations.

Surgery can be another cause of endometrial cell displacement. A typical example of such "mechanical" endometrial transfer isendometriosisin the cesarean scar.

  • theory of endometrial cell formation

In addition to cell proliferation through retrograde menstruation, it is also possible for endometrial cells to form spontaneously in a variety of locations. It can take place in the process of the so-called metaplasia, that is, transforming one type of cell into another. Another proposed mechanism is the formation of endometrial foci from stem cells that retain the ability to transform into any type of tissue.

  • immune theory

One of the probable mechanisms that increase the risk of developingendometriosisas a result of residual menstrual blood is a disruption of the immune system. In a properly functioning organism, the remnants of monthly blood should be "cleaned up" by the cells of the immune system. Impairment of their activity may increase the risk of endometrial cells surviving in the wrong location.

  • genetic theory

So far, no single gene has been identified responsible for the development ofendometriosis . Several different gene variants are more likely to be affected. Although the findings here are vague, the involvement of genetic factors has been confirmed in studies on identical twins. The occurrence ofendometriosisin close relatives (mother, sisters) is associated with an increased risk of developing the disease.

  • environmental theory

Environmental factors may play an additional role in the development ofendometriosis . According to some studies, a diet restricted in red meat may reduce the risk of developing the disease. In turn, an increased risk may be associated with exposure to certain chemicals (for example, dioxins that are harmful to humans).

  • hormone theory

Endometrial tissue outside the uterus behaves exactly like the tissue in the right place. It undergoes cyclical reconstruction along with changes in the concentration of sex hormones during the cyclemenstrual. It is believed that hormonal factors can influence both the survival of endometrial cells in unusual locations and their ability to grow and multiply.

Types of endometriosis

Different classification systems are used to describeendometriosis , based on, for example, the location or severity of changes.

The basic division covers three types of endometriosis:

  • peritoneal endometriosis

In the peritoneal form, fociendometriosisare attached to the surface of the peritoneum, the thin membrane surrounding the abdominal and pelvic organs.

  • ovarian endometriosis

Ovarian endometriosisusually takes the form of endometrial cysts. Endometrial cells implanted within the ovary grow and cause local monthly bleeding, thus forming cysts. Due to the characteristic appearance of their contents, they are called chocolate cysts. Endometrial cysts are most often located in the ovaries, although they may also appear elsewhere in the pelvis or abdominal cavity.

  • deeply infiltrating endometriosis

The last typeendometriosisis a deeply infiltrating character. In this variant, the endometrial tissue shows high proliferative activity, passes through the peritoneum and infiltrates more than 5 mm beyond its surface. The infiltration may involve the surrounding organs: bladder, ureters, rectum, and other parts of the intestine.

Endometriosis Severity

In order to standardize the method of describing the advancement of the disease, the ASRM (American Society for Reproductive Medicine) classification was introduced. It is a four-step scale based on the number, type and size of fociendometriosis , infiltration of surrounding tissues, and the presence of additional lesions (for example, adhesions).

Endometriosis Severity According to ASRM Score

  • Grade I (minimal) - slight changes (less than 5 mm) are visible, and in the fallopian tubes and ovaries there are non-vascularized adhesions and free hyphae of the fallopian tubes
  • stage II (benign) - changes in the ovaries have a diameter of more than 5 mm, adhesions appear between the wide ligaments and the ovaries, and in the fallopian tubes and ovaries; fociendometriosiscan also be observed in the recto-uterine cavity, endometrial (chocolate) cysts appear
  • grade III (moderate) - broad (sacro-uterine) ligaments are in adhesions with the ovaries or fallopian tubes, adhesions also occur in hyphaefallopian tubes, and in ovarian adhesions fociendometriosis , in the recto-uterine cavity
  • stage IV (severe) - the uterus is immobile, adhesively attached to the intestines, or displaced posteriorly. The intestines are in adhesions with the peritoneum of the recto-uterine cavity, the recto-uterine ligaments, or the endometrium; endometriosis outbreaks appear in the bladder, appendix, vagina, cervix

Interestingly, the above classification only assesses the advancement of changes in the context of their external description. However, it does not have any impact on the degree of discomfort experienced by the patients.

Endometriosisin the first degree may cause very intense pains, but it happens that a disease that is very advanced according to this scale does not give any symptoms. The stage of advancement does not correlate with the risk of other complications of the disease, such as, for example, infertility.

Endometriosis diagnosis

Endometriosis diagnosis includes :

  • thorough interview. The mere description of ailments and symptoms experienced by the patient may direct the doctor's suspicion towards this disease.
  • gynecological examination. During examination with the use of specula, foci ofendometriosismay be seen, e.g. in the vaginal wall. On the other hand, palpation (by touch) may reveal soreness of the reproductive organ, abnormal lumps, lumps and lesions consistent with endometrial cysts.
  • The presence of the latter can also be confirmed by imaging tests (transvaginal ultrasound or, less frequently, magnetic resonance imaging).
  • If you suspectendometriosisdeeply infiltrating, located near the large intestine, you can additionally perform a transrectal ultrasound.
  • By far the best and most accurate method of diagnosisendometriosisis exploratory laparoscopy. Special tools are introduced through the abdominal wall, along with a miniature camera, which allows for a detailed examination and assessment of disease outbreaks.
  • Laparoscopy also allows you to take biopsies, which are then subjected to microscopic analysis to confirm the diagnosis. During the procedure, it is also possible to use surgical methods of treatmentendometriosis .
Prof. Paweł Blecharz

Prof. dr hab. n. med. Paweł Blecharzspecialist in gynecology oncology from the private Specialist Hospital SCM clinic in Krakow (www.scmkrakow.pl). She deals with diagnostics and surgical treatment of female neoplasmsgenital organs and conducting chemotherapy in patients with these tumors.

Difficult diagnosis

Detectingendometriosisis not always easy, as often ultrasound examinations and even MRI results are not clear cut. Therefore, the diagnosis of this disease is a combination of an interview with the patient, clinical examination and imaging examination. If the disease is still uncertain, serum biomarker tests are performed.

Ca125 marker may be elevated inendometriosisand ovarian cancer. Its correct interpretation will make the diagnosis more precise. The last examination combined with a procedure that allows for the final assessment of what is happening in the pelvis is laparoscopy.

In more doubtful cases, you can consider the diagnosis through therapy, that is, the introduction of hormone treatment, even if you are not sure about the diagnosis. Often, an improvement in the patient's condition is achieved then, because the pain is diminished. This may indicate that we were indeed dealing with the difficult to diagnose variantof endometriosis .

This method works well for women who do not see the justification for the surgery. The optimal situation is one in which a histopathological examination (i.e. examination of the surgical material of a cyst or a specimen) confirms the disease. However, sometimes, even then, the presence of endometrial tissues cannot be definitively determined. Then the final diagnosis is made on the basis of the intraoperative image in laparoscopy, which is rather unambiguous for an experienced operator.

Treatment of endometriosis - two treatment options

Since the mechanisms of the formation ofendometriosisremain unclear, there is still no causal treatmenttreatment for endometriosis .

The therapy is therefore aimed at alleviating its effects and symptoms.

Treatment priorities are:

  • inhibition or removal of disease outbreaks
  • elimination of pain ailments
  • fertility restoration

There are two primary therapeutic pathways: pharmacological and operative. Both methods are often used together to increase the effects of treatment.

Pharmacological treatment of endometriosis

The most important groups of drugs used inendometriosisare painkillers, anti-inflammatory drugs and hormonal preparations. The latter are designed to arrest menstruation and / or reduce the concentration of estrogens in the body. In this way, their stimulating effect on the endometrium is reduced, which contributes toextinction of fociendometriosis .

This effect can be achieved in various ways: by suppressing the ovarian function (usually with combined birth control pills), increasing the effects of progesterone (which is opposite to estrogen), or by directly inhibiting the formation of estrogens.

Hormonal drugs are usually first-line therapy. If it is ineffective, surgical treatment may be necessary.

Hormone therapy is not used in patients who have problems with getting pregnant. Treatment of infertility related toendometriosisis most often operative (see below). If it is not effective, it may be necessary to use assisted reproductive techniques (for example, in vitro fertilization).

Surgical treatment of endometriosis

The type and scope of the surgery depends on the extent of the changes, as well as the age and expectations of the patients.

In the case of women planning a pregnancy, the most important aspect is to preserve their fertility. The treatments are then less radical -endometriosis foci are removed in such a way as to minimize damage to the ovariesand other organs of the reproductive system. During the operation, adhesions are also released in order to restore the normal anatomy of the reproductive organ.

Nowadays, most procedures are performed using the laparoscopic method. It is a less invasive procedure compared to operations involving the opening of the abdominal wall. Laparoscopy involves inserting an endoscope and other special instruments into the abdominal cavity through small incisions.

Treatments performed in patients who are not planning a pregnancy may be more radical. They involve bilateral removal of the ovaries, sometimes combined with the removal of the uterus (hysterectomy).

  • Life after removal of ovaries and uterus

More extensive surgeries may also be necessary in patients with a form of deeply infiltrating endometriosis.Excision of disease foci may require removal of fragments of other organs, for example the bladder wall or part of the intestine thick.

Regardless of the chosen method of treatment, we must be aware thatendometriosisis a chronic disease - despite the initial effectiveness of the therapy, the symptoms may recur. The more complete removal of disease lesions during surgery, the greater the chance of long-term improvement.

Hormone treatment usually helps to control pain, however it usually has to be used chronically - attempts to withdraware often associated with the recurrence of bothersome symptoms.

Until the exact causes of the outbreaks are knownendometriosis , unfortunately it will not be possible to counteract the mechanisms underlying the disease.

According to an expertProf. Paweł Blecharz

What determines the treatment of endometriosis?

The choice of the method of fightingendometriosisdepends on several factors: the type and severity of the disease and the effects expected by the patient.

The therapeutic path for painfulendometriosisdepends on its form. Ovarian endometrial cysts larger than 4 cm are usually surgically removed. The method of choice is their enucleation by a minimally invasive method during laparoscopy, as this problem usually affects young women.

This technique allows you to maintain or enhance fertility while providing a good cosmetic effect. Laparoscopy also has the advantage over the open method procedures that it causes the formation of postoperative adhesions to a much lesser extent. And these can even impair a woman's fertility and cause pain, so avoid opportunities for them.

In the case of fociendometriosison the peritoneum, i.e. small inflammatory implants, selective destruction techniques are used. You can perform these procedures with the use of electric current or in a more advanced way - argon or plasma. The latter two methods require more sophisticated equipment, but are also used in the medical market today. They allow, rather superficially, without damaging deeper structures, to burn small foci, eliminating the source of pain.

A bigger problem is removing the advanced stage of the disease, i.e.endometriosisdeeply infiltrating. Eliminating such changes is much more difficult because it is often associated with very extensive surgical procedures. Due to the location ofendometriosisdeeply infiltrating the pelvic floor, it often requires resection of a part of the intestine.

Such a procedure is associated with the risk of serious complications, including leakage of the intestinal anastomosis, which in turn can cause peritonitis. This requires reoperation and usually a stoma. Therefore, women whose symptom ofendometriosisis only pain, or who are undergoing treatment for infertility, should carefully consider the decision about such a procedure. The consequences to be reckoned with after surgery are sometimes much more serious than the symptoms of the disease itself. Then it is worth considering other, conservative methods of treatment.

Prof. dr hab. n. med. Paweł Blecharz specialist in gynecology oncology from the private Specialist Hospital SCM clinic in Krakow (www.scmkrakow.pl). She deals with diagnostics and surgical treatment of female genital neoplasms as well as conducting chemotherapy in patients with these neoplasms.

Worth knowing

Is endometriosis cancer?

As mentioned above, mucosa implants behave similar to the mucosa they detached from. Similar but not identical. Simply put, under the influence of hormonal changes during the cycle, cells in implants, like endometrial cells, grow and then flake off during menstruation. Exfoliation is accompanied by slight bleeding. It means that every month, apart from menstruation, there is also a kind of parallel "menstruation", but outside the uterine cavity. Since the blood from these implants does not have a natural outlet, it forms adhesions that continue to grow with subsequent menstruation.

Endometriosisis not a neoplastic disease. Implant cells have some features of cancer - they cause local inflammation. The immune system should annihilate them, but it can't cope with them any more than it can with cancer cells. Over time, implants turn into tumors that produce, like tumors, a network of blood vessels through which they feed. Although there are more analogies, this disease is not cancer.

Category:

Female diseases