Content

Introduction

Introduction

Endometriosis is a condition that develops when the mucous membrane that lines the uterus, called endometrium, is located outside the uterus.

Even when the endometrium is located in places other than the uterus it maintains the same characteristics so that every month, under the stimulation of the hormones produced by the ovaries, it thickens and then flakes off causing a "pseudo menstruation" that causes pain, sometimes very intense, especially during menstrual flow.

The most frequent sites for abnormal endometrial tissue implantation are the ovaries, fallopian tubes or the inside of the pelvis (lower abdomen) including the bladder and intestines.

The surrounding tissues can undergo the formation of adhesions sometimes responsible for infertility.

Spread outside the pelvic organs is very rare.

It is a disorder that usually appears several years after the start of menstruation. The signs and disorders (symptoms) caused by endometriosis improve during pregnancy and stop with menopause, unless the woman takes estrogen hormones.

Symptoms

Symptoms

The main complaint (symptom) is pelvic pain, often associated with menstrual flow. It is a much more intense pain than what usually occurs during menstruation and tends to increase in intensity over the years.

Women with endometriosis report a variety of ailments, the most common of which include:

  • pain in the lower abdomen or in the back (pelvic pain), usually worsening during menstruation
  • pain related to menstruation (dysmenorrhea), of such intensity that it can be very disabling
  • pain during or after sexual intercourse
  • pain when urinating or freeing the intestine (evacuation), especially during menstrual flow
  • heavy menstruation or blood loss between one flow and another
  • difficulty getting pregnant (infertility)
  • feeling unwell
  • constipation
  • diarrhea

In some cases, the disorders can have a severe impact on women's daily lives.

It is advisable to contact your doctor if they are of such intensity as to compromise the performance of normal activities.

It should be borne in mind that it can be difficult to ascertain (diagnose) endometriosis due to the variability of the disorders (symptoms) and their similarity to those caused by other diseases or conditions such as, for example, ovarian cysts or irritable bowel syndrome. which can also be associated with endometriosis complicating its assessment.

Causes

Causes

The causes of endometriosis are not known; however, possible explanations for its occurrence include:

  • retrograde menstruation, it occurs when, during the menstrual flow, some tissue fragments of the endometrium, instead of being eliminated externally, move in the opposite direction going up in the pelvic region through the fallopian tubes. These endometrial cells adhere to the wall of the pelvis or the organs it contains, such as the ovaries or bladder, and grow. Monthly, in correspondence with the menstrual flow, they cause pseudo-menstruation in the places where they are located
  • transformation of peritoneal or embryonic cells, it is hypothesized that hormonal or immune factors can promote the transformation of peritoneal or embryonic cells into endometrial cells
  • endometrial cell transport, it is hypothesized that endometrial cells can be transported out of the uterine cavity through blood vessels or the lymphatic system (a series of channels and glands that make up the immune system)
  • surgical wound implant, following a surgery involving the uterus, such as cesarean delivery or hysterectomy, endometrial cells can take root at the surgical incision
  • disorders of the immune system, it is hypothesized that they may hinder the recognition and destruction of endometrial tissue that grows outside the uterus

To date, none of these hypotheses is able to explain the origin of endometriosis and probably several factors contribute to determining it.

Diagnosis

Diagnosis

To ascertain (diagnose) the presence of endometriosis, the doctor inquires about present and past diseases (anamnesis) and asks the woman to describe the complaints she feels and to specify the location of the pain.

You can order tests that include:

  • gynecological examination, to look for indirect signs of endometriosis such as, for example, any enlargement of the ovaries
  • pelvic ultrasound, often transvaginal to examine in detail the uterus, ovaries and pelvic area and identify any cysts associated with endometriosis (endometrioma). Even this examination does not provide certainty that it is endometriosis
  • laparoscopy, the only examination capable of determining with certainty the presence of endometriosis. It is not performed as a first choice because it is invasive, it requires general anesthesia and the insertion of a fiber optic instrument (laparoscope) into the abdomen, through a small incision in the skin , to allow the surgeon to directly visualize the presence of endometrial tissue outside the uterus. Laparoscopy provides information on the localization, spread and size of endometrial implants allowing for the best possible treatment opportunities
Complications

Complications

The main complication of endometriosis is the difficulty or inability to become pregnant (infertility). It affects one third to half of women who suffer from it. The most frequent causes of infertility are due to obstruction or distortion of the tubes. Fallopian following the development of adhesions caused by endometriosis.

In some cases, when fragments of tissue from the endometrium are positioned close to the ovaries, adhesions or ovarian cysts can form which can enlarge and cause pain. In both cases, surgery can be performed, but it is not excluded that in the future can manifest themselves again.

Therapy

Therapy

The treatment (therapy) of endometriosis is not simple and generally involves medical or surgical treatment, based on the severity of the signs and disorders (symptoms) and the desire to have children.

Surgery is usually used after medical treatment.

Sometimes, if the complaints are mild, if there are no fertility problems or if you have an age close to menopause, a period in which the problems tend to disappear spontaneously, it may not be necessary to undergo treatment. Endometriosis, in fact, it is a disorder that in some cases tends to regress spontaneously; in others, it can get worse if nothing is done. It is therefore necessary to keep the disorders and their evolution under control over time to intervene in case they worsen.

In order to know the risks and benefits of each treatment, it is necessary to speak to the gynecologist, bearing in mind:

  • your age
  • most relevant disorders, (eg, only pain or difficulty getting pregnant)
  • desire for pregnancy
  • attitude towards surgery
  • therapies already carried out to combat endometriosis

In addition to consulting your doctor, it may also be helpful to contact a support group for women with endometriosis for guidance and advice.

Medicines to control pain

Anti-inflammatories with pain relieving properties, such as ibuprofen or naproxen, can help relieve menstrual pain. It is best to consult your doctor if the pain persists after taking painkillers for a few months.

Hormone treatment

The intake of hormones limits or inhibits the production of estrogen which is responsible for the thickening of the endometrial tissue and its flaking. Hormones can, therefore, reduce pain and prevent the formation of new implants but having no effect on the formation of adhesions, they are not effective in preventing infertility.

The intake of hormones can occur through:

  • contraceptive pill
  • vaginal ring (hormonal slow-release contraceptive ring)
  • contraceptive patch

Especially when used without monthly suspension, hormones can reduce or eliminate pain in mild or moderate endometriosis by stopping ovulation and making menstruation less abundant and less painful. When they are stopped, the disorders (symptoms) may reappear and it is still possible to seek pregnancy

  • drugs analogous to hormones that stimulate the release of gonadotropins (hormones that have a stimulating effect on the reproductive organs), blocking the production of ovarian hormone release factors, reduce estrogen levels and prevent menstruation even in the sites of endometriosis. These are synthetic hormones that create a sort of menopause artificial. The treatment is not compatible with the search for pregnancy. The undesirable effects consist, as in the case of menopause, in hot flashes, vaginal dryness and decreased sexual desire
  • progestin hormone therapy, in the form of a pill or intrauterine device (coil or medicated IUD) that releases the hormone into the uterine cavity preventing the thickening of the mucous membrane that lines the uterus, helping to reduce the pain of menstruation until it can also cause stopping of the menstrual cycle
  • called synthetic hormones pro-gestational (pro-pregnancy), act like progesterone, which is a natural hormone, to prevent the thickening of the membrane that lines the uterus and therefore the onset of endometriosis.They are generally taken as tablets from the 5th to the 26th day of the menstrual cycle. They can cause side effects such as swelling, mood swings, irregular bleeding or weight gain. They have no contraceptive effect
  • anti-progestational hormones, for example danazol, act similarly to hormone analogs of the hormone stimulating the release of gonadotropins. They cause a state of temporary menopause by reducing the production of estrogen but can have serious undesirable effects (side effects) (weight gain, acne, changes in mood and development of masculine traits such as increased body hair and low tone of voice) for which they are very rarely prescribed. maximum 6 months

The evidence of efficacy of these treatments is equivalent, but the side effects vary: they are more frequent and of greater importance in case of use of progestational and anti-progestational hormones which, for this reason, are rarely prescribed.

Conservative surgery

If pregnancy is sought, removing most of the endometriotic tissue, preserving the uterus and ovaries, can facilitate conception. These are interventions usually performed laparoscopically to remove or eliminate parts of the tissue of the endometrium, in order to alleviate symptoms and not compromise fertility.

Assisted reproduction techniques

If conservative surgery fails, or as a first-line therapy, these techniques, which include in vitro fertilization, can increase the chances of getting pregnant.

Hysterectomy

If the minimally invasive surgery techniques have not been successful and if there is no longer any desire for pregnancy, the alternative is to resort to the removal of the uterus (hysterectomy). It represents the last option in case of severe endometriosis. To prevent the production of hormones from continuing to cause disturbances, the removal of the ovaries must also be considered. Hormone replacement therapy can cause a resumption of the disturbances; therefore, the opportunity to resort to a hysterectomy should be carefully established with the doctor. Before undergoing surgery, it can be very important to get a second opinion to make sure you know all the therapeutic options.

Complementary therapies

At present, there is no evidence of efficacy showing that traditional Chinese medicine, or any other type of complementary medical treatment, can offer a remedy for treating endometriosis.

Bibliography

Bibliography

Indraccolo U, Indraccolo SR, Mignini F. Micronized palmitoylethanolamide / trans-polydatin treatment of endometriosis-related pain: a meta-analysis. Annals of the "Istituto Superiore di Sanità".2017; 53: 125-134.

In-depth link

In-depth link

Italian Endometriosis Foundation. Endometriosis

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Endometriosis (English)

Mayo Clinic. Endometriosis (English)

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