Home Forums Obstetrics & Gynaecology ENDOMETRIOSIS

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    Endometriosis refers to the abnormal presence of the uterine lining (endometrium) in various other sites in the body. It is a common condition affecting about 1 in 10 women in the reproductive age. Diagnosis is usually made when the woman is in her thirties

    • Ovaries
    • Fallopian tubes
    • Peritoneum
    • External surfaces of the uterus, bladder, ureters, rectum and intestines
    • Cul-de-sac (the space behind the uterus)

    The exact cause is not known but several theories have been proposed to explain the presence of ectopic endometrial tissue

    • Retrograde menstruation theory – Menstrual blood flows back from the uterus into the tubes and escapes into the peritoneal cavity instead of flowing out of the vagina

    • Mullerian theory – Endometrial cells misplaced outside uterus during fetal period begin to respond to the hormonal changes that occur at puberty

    • Hormonal theory – Under hormonal influence, the cells of organs outside the uterus change into endometrial lining cells

    • Surgical theory – Endometrial tissue can escape into the pelvic cavity through a surgical scar on the uterus eg following a cesarean delivery

    • Stem cell theory – Cells in the body are derived from embryonic cells capable of forming all tissues and in certain parts of the abdomen, these embryonic cells become endometrial cells

    • Transport of endometrial cells by lymphatic system

    • Dysfunctional immune system – Disorderly immune system fails to destroy and remove endometrial cells in ectopic sites

    • Possible genetic and environmental influences

    The endometrial tissue present in ectopic sites responds to hormones in a similar fashion as normally occurring endometrial tissue. It grows in response to hormones and breaks down and bleed during the time of the menstrual period. The various symptoms and signs of endometriosis include the following

    • Severe pain during periods since blood collects in the pelvis with no escape route
    • Irritation and inflammation of pelvic tissue
    • Healing of inflamed tissue with scarring
    • Adhesions of scar tissue with adjacent organs
    • Pain during urination (endometriosis of bladder)
    • Pain while passing stools (endometriosis on rectum)
    • Pain during sex
    • Some women may be asymptomatic
    • Scarring of tubes may lead to infertility (most serious complication)

    The stages of endometriosis depend on the location, number of lesions, size, and depth of endometrial tissue in the ectopic sites. The stages include

    Stage 1: Minimal
    In minimal endometriosis, the lesions are small and few in number and usually consist of shallow endometrial implants on the ovary. There may also be associated mild inflammation in or adjacent to the pelvic cavity
    Stage 2: Mild
    Mild endometriosis refers to small lesions and shallow extent of endometrial implants on the ovary and the pelvic lining.
    Stage 3: Moderate
    Moderate endometriosis is said to occur when the implants extend deeper into the ovary and pelvic lining. There may be several lesions
    Stage 4: Severe
    The most severe form of endometriosis refers to deep implants on the ovaries and pelvis lining. Multiple lesions may be present on fallopian tubes bowels and other sites as well

    History and physical examination
    On presentation, the doctor will take a detailed history and a thorough physical examination including an internal pelvic examination to feel for possible scars or cysts adjacent to the uterus

    Ultrasound imaging
    A transvaginal ultrasound or an abdominal ultrasound imaging may be performed for a better view of possible cysts or other lesions in the tubes and ovaries. In a transvaginal ultrasound, a probe is inserted into the vagina. However, these are not very useful in ruling out endometriosis

    The only definitive method of diagnosing endometriosis is by direct visualisation to look for endometriosis lesions within the pelvis. This is achieved by a minor surgical procedure known as a laparoscopy performed under general anesthesia. A thin illuminated tube is inserted into the pelvic cavity through a tiny incision made on the abdomen. During the procedure, a sample of possible endometriosis tissue may be obtained for microscopic analysis

    Sometimes it may be possible to treat mild endometriosis when the lesions are few in number and not extensive to avoid a further operation. In some cases, the nature and extent of lesions seen on laparoscopy may necessitate further tests or treatment

    There is currently no cure for endometriosis but the symptoms can be effectively managed. Depending on the age of the patient and severity of the condition, treatment can be medical or surgical

    PAIN KILLERS – Over the counter pain medications such as ibuprofen and naproxen can be tried but may not be effective in all cases

    Hormone supplements are sometimes effective in reducing or eliminating the pain of
    endometriosis. They act by slowing endometrial tissue growth and prevent newer implants of endometrial tissue from forming. However hormones may not cure the conditions and symptoms may recur on stopping treatment. Hormone therapy includes the following

    • Hormonal contraceptives – They can be administered as birth control pills, vaginal rings or patches. Most women have lighter and shorter menses while on a hormonal contraceptive.

    • Progestin therapy – Various forms of progesterone treatment including intrauterine device (Mirena), progestin pills, contraceptive implant, or contraceptive injection (Depo-Provera) can stop the periods and the growth of endometrial tissue in ectopic sites and relieve symptoms

    • Gonadotropin releasing hormone agonists and antagonists – These block the formation of estrogens from the ovary and prevents menstruation thereby creating an artificial menopause. This treatment may cause vaginal dryness and hot flashes. Taking small doses of estrogen and progesterone simultaneously can prevent these

    • Aromatase inhibitors – These are a class of drugs that reduce estrogen levels. In some cases aromatase inhibitor along with progestin or combination pill may be advised

    This is conservative surgery performed to remove the endometrial implants while conserving the uterus, ovaries and tubes. Laser treatment is used to destroy this ectopic tissue nowadays

    Women with endometriosis have trouble conceiving and can discuss assisted reproductive techniques to get pregnant.

    Rarely, a total hysterectomy with removal of ovaries along with all visible endometrial implants may be advised as a last resort if the condition does not respond to other measures. tissue. This treatment is not suitable for women who wish to become pregnant

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