Endometriosis

Endometriosis
Name	Endometriosis
Field	Gynecology, Reproductive endocrinology and infertility
Symptoms	Pelvic pain, Dysmenorrhea, Dyspareunia, Infertility
Complications	Ovarian cyst, Adhesion (medicine), Chronic pain
Causes	Unknown, theories include Retrograde menstruation, Coelomic metaplasia
Risks	Family history, early Menarche, short Menstrual cycle
Diagnosis	Laparoscopy, Medical imaging, Biopsy
Differential	Pelvic inflammatory disease, Irritable bowel syndrome, Interstitial cystitis
Treatment	Analgesic, Hormonal therapy, Laparoscopic surgery, Hysterectomy
Medication	Nonsteroidal anti-inflammatory drug, Combined oral contraceptive pill, Progestin, Gonadotropin-releasing hormone agonist
Frequency	~10% of reproductive-age women

Endometriosis. It is a chronic Estrogen-dependent condition where tissue resembling the Endometrium grows outside the Uterus, primarily within the Pelvic cavity. This ectopic tissue responds to hormonal fluctuations, leading to inflammation, pain, and the formation of scar tissue known as Adhesion (medicine). The disease significantly impacts quality of life and is a major contributor to Infertility and Chronic pain syndromes.

Definition and Overview

Endometriosis is defined by the presence of endometrial-like Glands and Stroma on extra-uterine sites, most commonly affecting the Ovaries, Uterosacral ligament, and Peritoneum of the Pelvis. The condition was first described in detail by pathologist John A. Sampson in the 1920s, who proposed the theory of Retrograde menstruation. Key organizations like the American Society for Reproductive Medicine and the World Endometriosis Society work to standardize its classification, such as the revised American Society for Reproductive Medicine staging system. The disease process involves complex interactions between endocrine and Immune system factors, leading to Neuroangiogenesis and Inflammation.

Signs and Symptoms

The cardinal symptom is Pelvic pain, often cyclical and worsening during Menstruation, known as Dysmenorrhea. Dyspareunia is common, alongside Chronic pelvic pain syndrome. Gastrointestinal symptoms like Dyschezia can occur with Rectovaginal septum involvement, while Urinary system symptoms may suggest Bladder implants. A significant proportion of patients with Infertility are found to have the condition during investigations like Diagnostic laparoscopy. Other manifestations include Fatigue and Catamenial symptoms such as Catamenial pneumothorax.

Causes and Risk Factors

The exact etiology remains unclear, with several non-exclusive theories prevailing. John A. Sampson's theory of Retrograde menstruation is the most cited, suggesting reflux of Menstrual fluid through the Fallopian tubes. Alternative hypotheses include Coelomic metaplasia, where Peritoneal cells transform, and Lymphatic or Vascular spread. Genetic predisposition is strong, with higher incidence among first-degree relatives, and research by institutions like the Wellcome Trust Centre for Human Genetics has identified associated loci. Risk factors include early Menarche, short Menstrual cycles, and Müllerian duct anomalies.

Diagnosis

Definitive diagnosis requires Laparoscopic surgery with visual confirmation and histological Biopsy, as recommended by the European Society of Human Reproduction and Embryology. Pre-operative assessment includes a detailed Medical history and Physical examination, often noting tenderness in the Cul-de-sac or Uterosacral ligament. Transvaginal ultrasound, performed by specialists in Gynecologic ultrasonography, can detect endometriomas (Chocolate cysts) and deep infiltrating disease. Magnetic resonance imaging is useful for evaluating Uterosacral ligament and Rectovaginal septum involvement, while serum CA-125 levels are non-specific.

Treatment and Management

Management is tailored to symptoms and reproductive goals, involving a multidisciplinary team from Gynecology and Pain management. First-line Analgesic therapy often involves Nonsteroidal anti-inflammatory drugs like Naproxen. Hormonal therapy aims to induce Pseudopregnancy or Pseudomenopause, using agents such as the Combined oral contraceptive pill, Progestins (e.g., Dienogest), Gonadotropin-releasing hormone agonists (e.g., Leuprolide), and the Androgen Danazol. Laparoscopic surgery, often employing Excision or Ablation techniques, is used for diagnosis, pain relief, and improving fertility, potentially performed by specialists at centers like the Mayo Clinic. In severe cases, definitive surgery like Hysterectomy with Oophorectomy may be considered.

Epidemiology and Prognosis

Endometriosis affects approximately 10% of women of reproductive age globally, with prevalence estimates from studies like the Nurses' Health Study II. Diagnosis is often delayed, with an average lag of 7-10 years from symptom onset, as highlighted by organizations like Endometriosis UK. The condition is a leading cause of Infertility, present in up to 50% of affected women. While not malignant, it carries an increased risk for certain Ovarian cancer histotypes, such as Endometrioid adenocarcinoma and Clear-cell carcinoma. Long-term prognosis varies, with many experiencing persistent symptoms requiring ongoing management from centers like the Royal College of Obstetricians and Gynaecologists.

Category:Gynecological disorders Category:Chronic pain Category:Infertility