superficial peritoneal endometriosis, ovarian endometrioma, deep infiltrating endometriosis
Endometriosis is a common gynecologic disorder. The estimated frequency among women of reproductive age is 5%–10% and is particularly frequent among women with pelvic pain and infertility. Around 50% women with pelvic pain suffer from endometriosis. It most commonly affects women in their 20’s and 30’s. This disorder is classically defined as the presence of endometrial glands and stroma outside of the endometrial lining and uterine musculature. The exact etiology of endometriosis has yet to be elucidated. Mechanistic theories include: the reflux of endometrial tissue through the fallopian tubes at the time of menstruation, coelomic metaplasia, embryonic cell rests, and lymphatic and vascular dissemination.
The theory of retrograde menstruation (also called the implantation theory or transplantation theory) is the most widely accepted theory for the formation of ectopic endometrium in endometriosis. It suggests that during a woman's menstrual flow, some of the endometrial debris exits the uterus through the fallopian tubes and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as endometriosis. While most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevent implantation and growth of cells from this occurrence. However, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis. Factors that might cause the tissue to grow in some women but not in others need to be studied, and some of the possible causes below may provide some explanation, e.g., hereditary factors, toxins, or a compromised immune system. It can be argued that the uninterrupted occurrence of regular menstruation month after month for decades is a modern phenomenon, as in the past women had more frequent menstrual rest due to pregnancy and lactation. Retrograde menstruation alone is not able to explain all instances of endometriosis, and it needs additional factors such as genetic or immune differences to account for the fact that many women with retrograde menstruation do not have endometriosis. However, it is generally accepted that endometriosis has a multi-factorial etiology, including genetic, hormonal and immunological factors. Areas commonly affected by endometriosis include the surface of the ovaries and the pelvic peritoneum and can result in pelvic inflammation, adhesions, chronic pain and infertility. Endometrial cells in areas outside the uterus are also influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. While endometriosis is a benign lesion, it shares several characteristics with invasive cancer. Similar to cancer, endometriosis has the capacity to invade and spread distantly. Endometriosis can attach to, invade and damage affected tissues. In addition, numerous studies indicate that women with endometriosis have an increased risk of developing epithelial ovarian cancer (EOC).
There is no cure for endometriosis, but it can be treated in a variety of ways, including pain medication, hormonal treatments, and surgery.Tentative evidence suggests that the use of combined oral contraceptives reduces the risk of endometriosis. Exercise and avoiding large amount of alcohol may also be preventative.
Types of endometriosis - Staging
Surgically, endometriosis can be staged I – IV (Revised Classification of the American Society of Reproductive Medicine). The process is a complex point system that assesses lesions and adhesions in the pelvic organs, but it is important to note staging assesses physical disease only, not the level of pain or infertility. A person with Stage I endometriosis may have little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings:
Stage I (Minimal)
Findings restricted to only superficial lesions and possibly a few filmy adhesions (are fibrous bands that form between tissues and organs).
Stage II (Mild)
In addition, some deep lesions are present in the cul-de-sac (recto-uterine pouch - the extension of the peritoneal cavity between the rectum and the posterior wall of the uterus in the female human body).
Stage III (Moderate)
As above, plus presence of endometriomas on the ovary and more adhesions.
Stage IV (Severe)
As above, plus large endometriomas, extensive adhesions.
Even though the endometrioma of the ovary reacts poorly to hormone therapy, nowadays smaller endometriomas (approximately 2-3cm) are not removed surgically to avoid unnecessarily reducing the ovarian reserve.
A larger endometrioma, for example 40-50mm, can be surgically removed if it would constitute an obstacle to the egg collection included in the IVF program.
Ovarian stimulation does not aggravate the course of the endometriosis.
Eliminate the endometrioma with caution in order not to significantly reduce the ovarian reserve.
The worst is repeatedly interfering with the woman's organism and repeatedly operating the consequences of endometriosis.
Current research has demonstrated an association between endometriosis and certain types of cancers, notably some types of ovarian cancer, non-Hodgkin's lymphoma and brain cancer. Despite similarities in their name and location, endometriosis bears no relationship to endometrial cancer. Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders.
Complications of endometriosis include internal scarring, adhesions, many adhezions are called frozen pelvis.
Infertility can be related to scar formation and anatomical distortions due to the endometriosis.It is a mechanical factor.However, endometriosis may also interfere in more subtle ways by biochemical factor. It means cytokines and other chemical agents may be released that interfere with reproduction (low fertilization of oocytes,decreased endometrial receptivity,decreased embryo nidability). Ovarian endometriosis (cysts) can be complicated by its rupture or torsion around own axis. Cysts significantly reduce ovarian tissue - functional parenchyma. Bowel and ureteral obstruction resulting from pelvic adhesions.
The following factors may place you at greater risk for developing endometriosis :
Endometriosis can cause infertility. In endometriosis, there is a risk of female infertility of up to 30% to 50%. The abnormal growth of endometrial tissue with each female hormonal cycle causes adhesions and scars from forming in the organs where it is. This, in the case of the female reproductive organs can be fatal for the smooth passage of the ovum to the uterus.
The mechanisms by which endometriosis may cause infertility is not clearly understood, particularly when the extent of endometriosis is low.
Still possible mechanisms include:
The other way around, endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon. For this reason it is preferable to speak of"endometriosis-associated infertility" rather than any definite "infertility caused by endometriosis" by the same reason that association does not imply causation.
Only surgical treatment has been shown to improve the fertility of patients whose infertility was thought to be due to endometriosis. One study has shown that surgical treatment of endometriosis approximately doubles the fecundity (pregnancy rate).
In younger women with unfulfilled reproductive potential, surgical treatment attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue.
It is recommended that the small cysts do not operate at all to reduce the valuable ovarian parenchyma.
The use of medical suppression after surgery for minimal/mild endometriosis has not shown benefits for patients with infertility. It is advisable to stimulate the patient immediately after the chirugical exercise in the IVF treatment program. Ovarian stimulation does not aggravate the course of the endometriosis. Use of fertility medication that stimulates ovulation (clomiphene citrate, gonadotropins) combined with intrauterine insemination (IUI) enhances fertility in these patients.
Limited evidence indicates that the use of combined oral contraceptives is associated with a reduced risk of endometriosis.
As surgical and hormonal treatment of endometriosis have unpleasant side effects and high rates of relapse, many patients began to explore more natural and traditional remedies. In China, treatment of endometriosis using Chinese herbal medicine is routine to alleviate pain, promote fertility, and prevent relapse. However, due to the limited amount intervention studies reported, more rigorous researches are required to accurately assess the type, dose and potential role of Chinese herbal medicine in treating endometriosis.
Long-term medical treatment is usually needed in most women. Unfortunately, in most cases, pain symptoms recur between 6 months and 12 months once treatment is stopped. Current treatment of endometriosis is mainly based on surgery (Laparoscopic procedure with laser and/or electrocautery to ablate the lesions and lyse the adhesions, removal of endometriomas, hysterectomy and oophorectomy to prevent cycling) and ovarian suppressive agents (oral contraceptives, progestins, GnRh agonist and androgenic agents).
Non-steroidal anti- inflammatory agents
With attention to inflammatory nature of endometriosis, for decades non- steroidal anti-inflammatory agents (NSAIDs) such as naproxen and ibuprofen have been administrated for pain control, in endometriosis. These drugs have been reduced prostaglandins (PGs) production, the main stimulator factor in peritoneal nerves and decrease the nociceptor input messenger from the peritoneal endometriotic implants into central nervous system.
Hormonal treatments currently available are effective in the relief of pain associated to endometriosis. Among new hormonal drugs, association to aromatase inhibitors could be effective in the treatment of women who do not respond to conventional therapies. GnRh antagonists are expected to be as effective as GnRH agonists, but with easier administration (oral).
Laparoscopy is nowadays considered best way. Interdisciplinary cooperation with urologists and surgeons is often necessary in the case of urinary tract or intestinal lesions.
Procedures are classified as conservative when reproductive organs are retained, semi - conservative when ovarian function is allowed to continue and radical surgery.
Conservative therapy consists of the excision of the endometriosis bearing, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible. Laparoscopy, besides being used for diagnosis, can also be an option for surgery. It's considered a "minimally invasive" surgery because the surgeon makes very small openings (incisions) at (or around) the belly button and lower portion of the belly. A thin telescope-like instrument (the laparoscope) is placed into one incision, which allows the doctor to look for endometriosis using a small camera attached to the laparoscope. Small instruments are inserted through the incisions to remove the tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure.
Semi-conservative therapy preserves a healthy appearing ovary, very important for women wishing to conceive, but also increases the risk of recurrence and should be performed by a skilled and qualified surgeon.
Removing the uterus , both ovaries, if possible, all of the endometriosis deposits, including adhesion disruption. It is performed in women who do not plan for pregnancy.
Other options for patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. However, strong clinical evidence showed that presacral neurectomy is more effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the pain extends to theleft and right lower quadrants of the abdomen.This is because the nerves to betransected in the procedure are innervating the central or the midline regionin the female pelvis. Furthermore, women who had presacral neurectomy have higher prevalence of chronic constipation not responding well to medication treatment because of the potential injury to the parasympathetic nerve in the vicinity during the procedure.
Surgical treatment of deeply infiltrating endometriosis with colorectal involvement belongs to the most difficult surgery, often inoperable matter.
Treatment should be considered individually, respecting the patient's wishes. The most important is the so-called first operation, every other operation (reoperation) leads to a number of problems and is associated with higher morbidity of the patient.
Controlled ovarian hyperstimulation, intrauterine insemination, or in vitro fertilization, are commonly used for endometriosis-associated infertility. Endometriosis impairs the efficacy of in vitro fertilization. IVF makes it possible to combine sperm and eggs in a laboratory and then place the resulting embryos into the woman's uterus. The decision when to apply IVF in endometriosis-associated infertility cases takes into account the age of the patient, the severity of the endometriosis, the presence of other infertility factors, and the results and duration of past treatments.
An abnormal condition in a woman's menstrual cycle.
An obstruction prevents the egg or sperm from traveling down the tube, thus making fertilization impossible.
A condition arising from an abnormal immune response to a normal body part.
Hematosalpinx is a medical condition involving bleeding into the fallopian tube.
Medical condition characterized by the presence of ectopic endometrial tissue within the myometrium.
A physical or psychological condition in which woman cannot engage in any form of vaginal penetration.
A type of female genital malformation resulting from an abnormal development of the Müllerian duct(s) during embryogenesis.
Congenital uterine malformation where both Müllerian ducts develop but fail to fuse, thus the woman has a "double uterus".
A hydrosalpinx is an abnormal pouch containing liquid in a fallopian tube.
A distally blocked Fallopian tube filled with pus.
Thickening of the lining of the uterus.
The most common benign smooth muscle tumors of the uterus encountered in women of reproductive age.
A type of cancer in which abnormal cells begin to grow in one or both of a woman's ovaries.
Narrowing of cervix - the opening to the uterus.
The luteinisation of ovulatory follicle without a release of an oocyte.
A form of abdominal adhesions in the pelvis.
The type of blockage that affects the part of the fallopian tube end towards the ovary.
A surgery performed to remove a woman's uterus.
Benign ovarian cysts containing thick, old blood that appears as a brown fluid.
Type of cancer arising from the lymphoid tissue.
A blockage of both fallopian tubes.
An excessive amount of estrogenic activity in the body.
A condition of blocked passage through one of the Fallopian tubes.
Two very fine tubes that transport sperm toward the egg, and allow passage of the fertilized egg back to the uterus for implantation.
The ovum-producing organs of the internal female reproductive system
Hollow, expandable organ serving as a reservoir for urine prior to its expulsion from the body.
The uterus is the largest and major organ of the female reproductive tract that is the site of fetal growth and is hormonally responsive
A multicellular diploid eukaryote in an early stage of embryogenesis, or development.
Cells composing an inner layer of the uterine lining.
The innermost layer of uterus forming the uterine lumen where the implantation of an oocyte happens.
A female germ cell involved in reproduction.
The primary female sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics.
Steroid hormone, secreted by the ovaries, whose function is to prepare the uterus for the implantation of a fertilized ovum and to maintain pregnancy.
The fusion of an ovum with a sperm to initiate the development of a new individual organism.
The very early stage of pregnancy at which the embryo adheres to the wall of the uterus.
The periodic discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina.
The process of the maturation of the female gametes through the meiotic division.
The release of egg(s) from the ovaries.
Changes in menstruation resulting from increased volume, duration, or frequency.
A congenital disorder where a hymen without an opening completely obstructs the vagina and with negative impact on female fertility.
Occurrence of menstruation in 11 years or less.
A complication of pregnancy in which the embryo attaches outside the uterus.
The cysts formed after ectopic adhesion (attachment outside the uterus) of endometrial tissue interfering with conception and pregnancy.
A higher risk of disease when multiple family members are affected.
Prolonged and also excessive uterine bleeding that occurs at irregular, frequent intervals.
Intrauterine death of an embryo or a fetus of less than 500g in mass or before 20 weeks of gestation.
Infection of the upper part of the female reproductive system and a common complication of some sexually transmitted diseases.
Type of lifestyle with no or irregular physical activity.
Toxins are small molecules, that are capable of causing disease on contact with or absorption by body tissues interacting with biologic macromolecules
The condition of having at least three loose or liquid bowel movements each day.
The onset of puberty before the average age in girls (8 years).
Abnormally heavy or prolonged bleeding in menstrual periods.
Bleeding that occurs irregulary between the menstrual period.
A common painful disorder involving the muscles and bones of the back.
The feel of pain during defecation.
Dysmenorrhea is a pain during menstruation. It is the most common menstrual disorder.
The painful feelings during sexual intercourse.
The presence of blood in the faecal discharge.
Retrograde flow of menstrual fluid through fallopian tubes into the pelvic cavity.
A term describing a person whose body weight is considered too low to be healthy.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
Surgical removal of the uterus.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
Use of laparoscopic technique to remove foci of endometriosis.
Surgical removal of one or both ovaries.
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.
Surgery used to treat severe pelvic pain that does not respond to previous therapy.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
A broad range of medicine practices sharing common concepts which have been developed in China and are based on a tradition of more than 2000 years.