Endometriosis, Pelvic Pain and Infertility

Introduction: as you will see in this article endometriosis must be identified before it becomes manifest. An early diagnosis is possible and can prevent the serious complications of this disease.

ENDOMETRIOSIS is without any doubt one of the greatest chapters of gynecology. It’s a disease that has unfortunately changed negatively the lives of many women, particularly when diagnosed late.

It is estimated that worldwide, endometriosis affects approximately 3-10% of women of reproductive age.  This data is very alarming when you consider that endometriosis often causes chronic pelvic pain, infertility and dyspareunia (pain during sexual intercourse). 25-35% of women with reproductive problems and 20-40% of women with chronic pelvic pain have endometriotic lesions.

Among adolescents with severe pelvic pain was estimated a prevalence of endometriosis of about 53%, which is really alarming. The social importance of the problem is given by the fact that it is the leading cause of gynecologic hospitalization in women aged between 15 and 44 years.

Endometriosis has no geographical or ethnic preferences but it is very rare before menarche and after menopause bringing the patients at a first diagnosis frequently between 20 and 35 years of age.

Described for the first time in 1921 by John Sampson is’ a benign disease caused by the

pelvic endometriosis

Pelvic endometriosis: the most common sites.

presence of endometrial-like tissue (the tissue that normally lines the uterine cavity) in ectopic sites outside the uterus. This lesions typically prefer the pelvis where can determine adhesions, cysts, bleeding and a broad spectrum of symptoms ranging from unexplained infertility in a woman completely healthy and asymptomatic acute abdomen requiring immediate surgical exploration. The organs most affected are the ovaries which can lead to the formation of cysts sometimes volumimose to content typically dark blood also called “chocolate cysts”, the tube, the surface of the uterus, the intestines, the peritoneum (the lining of the abdomen) . More rarely, it can affect other organs distant from the pelvis such as the lungs, brain and other soft tissues. Sometimes the endometrial tissue can locate surgical scars or on the cervix. Tends to expand and to recur and in the past, before the advent of medical therapy, women often wore several times on the operating table.

ETIOLOGY. But why so many women get sick of “endometriosis”? The first and oldest etiopatogenetic hypothesis formulated by the same Sampson in a historic publication of 1927 is that of retrograde menstruation: during menstruation some endometrial cells would follow a reverse path, moving along the tube and then taking root and growing in other organs. In fact the possibility of a retrograde menstrual flow has been demonstrated and seems also quite frequent but alone does not explain why many women in these cells do not take root and especially not explain localizations in organs far away from the abdominal cavity such as i.e. the brain, lungs and liver.

Some researchers have suggested a possible dissemination of endometrial cells through the lymphatic or hematogenous. Others Authors postulated in these patients an altered immune response as the “first cause” of the disease: a decreased function of natural killer cells and T cells may facilitate engraftment of endometrial cells outside the uterus but is not yet possible to exclude that these immune alterations are secondary to the disease itself.

In addition, we can not exclude a genetic predisposition: HLA-B7 expression is more frequent in these patients, and in fact often the the disease shows familial aggregation. To date, however, the true origin of the disease is unfortunately unknown and further studies will be needed.

SYMPTOMS. The ectopic endometrial tissue tends to

pelvic endometriosis and ovarian cyst

Diffuse pelvic endometriosis with ovarian cyst and hemoperitoneum

bleed as the endometrium intrauterine bleeding during menstruation. By the time the small areas tend to grow and may cause adhesions and scars; sometimes, especially on the ovary, cysts with the typical content of thick and dark blood.
The symptoms, especially in the early stages of the disease can be completely absent. Endometriosis has often been associated with an otherwise unexplained infertility whose causal moments are not yet fully known. Many patients complain of chronic pelvic pain and dyspareunia which is accentuated particularly in the proximity of the menses. The rupture of a cyst endometriosis can determine hemoperitoneum (blood loss in the abdomen) and thus also the dramatic clinical picture of acute abdomen.
When the disease is extended to urinary system and bowel can determine symptoms such as obstruction and bleeding.

MEDICAL THERAPY. Endometriosis is an endocrine-dependent disease and estrogen

ovarian endometriosis ultrasound

Ovarian endometriosis. Ultrasound is very useful for diagnosis and monitoring (follow-up).

undoubtedly have an important role in its development. The lack of identification of the cause in fact does not allow to date to carry an etiological therapy.

The estrogen and progestin sensitivity has allowed the development of different therapeutic approaches that include estrogen-progestin (the common oral contraceptive pill), progestin pills, GnRH analogues (that create a temporary menopausal status), Danazol (also administered by the vaginal route),  Gestrinone, progesterone-releasing intrauterine devices medicated IUD). Amenorrhea and hypoestrogenism sometimes necessary to reduce the disease have been better dealt with the development of “add-back therapy” to  limit symptoms and secondary effect such as hot flashes and loss of bone mineral content (Osteoporosis): usually after a few months of GnRH analogues alone start the association with transdermal systems (patches) or estrogen-progestin combined with Tibolone.

SURGICAL THERAPY in addition to cope with acute complications has the aim to perform a complete excision of all visible lesions that contribute to determining the pelvic pain as endometriotic cysts, adhesions, peritoneal outbreaks and those in localization in the recess rectovaginal and is generally a conservative surgery that uses always after surgery and sometimes even before (when possible and indicated) of medical therapy. The radical surgery, total hysterectomy with oophorectomy (removal of the ovaries) is always less frequent bilateral and reserves in selected cases of particular gravity.

The approach in videolaparoscopy (VLS) is considered the standard surgical method but the classic opening of the abdomen is often necessary (even during the same VLS) particularly in complex situations.

Our working group has reported in a limited number of patients treated in the onset VLS too late (late onset) of premature ovarian failure (POF): This rare event is not currently an explanation and deserves further investigation.

The NEW FRONTIERS of medical therapy include the use of aromatase inhibitors (the enzyme which causes the production of estrogen in the endometrium ectopic), anti-progestins, angiogenesis inhibitors, modulators of receptors for estrogen, anti-inflammatory agents and immunomodulators. More recently (June 2013) came into the market in Italy a new drug progestin existing overseas-based “dienogest” that without very promising and well-tolerated.

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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