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If the pain prevents you from enjoying intercourse, and during menstruation it does not allow you to function normally, check if you are one of the dozen or so percent of women who struggle with this disease. And although it was first described in 1690, knowledge about it is still small, even among doctors.
There are several theories about the causes of endometriosis, and none of them can explain the etiopathogenesis of this disease with certainty. On the one hand, it is believed that endometriosis develops in women whose menstrual blood is unable to flow out of the blood, i.e. it is draining backwards. But when you consider that endometrial lesions may appear in lung tissue or other organs distant from the uterus, the theory does not seem entirely true. More and more is being said about the effect of multipotent stem cells that can transform into endometrial cells. But this theory has as many supporters as opponents. So what is endometriosis and what determines its formation?
Endometriosis is the presence of endometrial glands and stroma outside the uterine cavity. Many healthy women have endometrial cells in the peritoneal cavity. So why don’t they develop endometriosis? The woman’s immune system is responsible for the entire process, which, when it is not working properly, enables the excessive development of these cells, which in turn leads to endometriosis. This disease affects mainly women of reproductive age, about 15 percent. menstruating and 50 percent. infertile in reproductive age. Retroflexion of the uterus occurs in a large group of women with this problem. But endometriosis can also be diagnosed in adolescents and postmenopausal women.
Symptoms of endometriosis
Endometriosis does not have one typical clinical picture. Depending on the severity and location of the endometriotic lesions, the disease may manifest itself in different ways.
Often these are pain, especially in the lumbar region, sacrum, and lower abdomen, which intensify during the perimenstrual period or during intercourse (dyspareunia). Painful menstruation is also typical, characterized by burning, jerky pain, and painful micturitions and defecations.
It happens that a woman visits a gynecologist because of spotting or bleeding prior to the menstrual period, as well as very heavy periods. It happens that endometriosis is accompanied by gastrointestinal bleeding and contact spotting (after sexual intercourse).
Often a woman also comes to the gynecologist with a request to confirm the diagnosis. Earlier, another doctor diagnosed her with a tumor. Careful examination shows that it is not a tumor but an endometrial cyst.
In some women, endometriosis can cause abdominal discomfort, intermenstrual spotting, which is most often wrongly attributed to cervical cancer. In more rare forms of endometriosis, intermittent haemoptysis, haemomycosis, and bloody stools may occur during menstruation. But the most common reason a woman sees her doctor is she has difficulty conceiving. It is estimated that 25-50 percent. infertile women have endometriosis and 30-50 percent. of patients with endometriosis has problems with conception. The cause of this condition is the adhesions formed in the course of endometriosis, which in the advanced form of the disease may lead to obstruction of the fallopian tubes or complete atresia of the smaller pelvis. This in turn inhibits the release of the oocyte from the ovary and its transport to the fallopian tube. Endometriosis can cause problems with sperm maturation, and the pain associated with it can lead to dyspareunia and reduce the chance of conception. The endocrine function of the ovaries may also be impaired, resulting in anovulation, luteinization of an unbroken follicle, or failure of the corpus luteum. Endometriosis contributes to the formation of autoantibodies to endometrial antigens, which may prevent implantation of the embryo or lead to spontaneous abortion.
But not every woman, even in advanced stages, does endometriosis with symptoms. And although there is no relationship between the severity of the disease and the clinical symptoms, the correlation between the severity of the disease and fertility is proven.
Endometriosis diagnosis
First, the doctor, during a gynecological examination, will assess the pain in the projection of the cruciate ligaments and when the uterus is moving. However, the confirmation of a normal condition in a gynecological examination does not exclude the occurrence of endometriosis. Reticulation of the uterus and limited mobility are common in this condition. In addition, the test allows for a certain diagnosis of only some forms of endometriosis, e.g. located in the caesarean scar, umbilical endometriosis and perineum. And when the clinical picture seems disturbing, the doctor may order a transvaginal ultrasound examination, which should be supplemented with a serum concentration test of CA-125. Although the examination is quite sensitive, it must be remembered that it only allows for the diagnosis of endometrial cysts greater than 10 mm. Peritoneal surface foci are not available in this study. In some situations, the physician may decide to invasively diagnose endometriosis during laparoscopic surgery.
Optimal treatment methods
Before deciding on the choice of treatment, the doctor will assess the likelihood of pregnancy without any treatment. Although the chance of conceiving in this group of women is smaller than in the general population, this does not mean that it is impossible to get pregnant naturally.
In the case of endometriosis related to infertility, the standard procedure is surgical treatment, which aims to excise all visible endometriotic lesions, which significantly improves fertility in women with first and second degree endometriosis (i.e. minimal and mild endometriosis). On the other hand, if a woman plans to become pregnant in the future, the doctor will most likely recommend pharmacotherapy. Invasive procedures are not recommended as they can lead to adhesions. Additionally, radical removal of endometrial cysts may be associated with a reduction in the ovarian reserve and fertility. However, in women who are not planning to have children, the doctor will recommend surgery.
Pharmacotherapy – birth control pills, painkillers
In the treatment of endometriosis, she uses birth control pills to stop abnormal bleeding related to the disease and symptomatically uses painkillers (non-steroidal anti-inflammatory drugs) to relieve mild pelvic pain. However, they do not inhibit disease progression. For many years, the only preparation was danazol, a testosterone derivative with a hyperandrogenic effect. The drug caused numerous disorders, such as hirsutism, male pattern baldness and even a change of voice. The preparations used today are characterized by a higher safety profile. Your doctor may prescribe gonadotropin releasing hormone (GnRH) agonists, which work by bringing about a hormonal state in the menopause, reducing gonadotropin secretion and, consequently, the production of estrogen. Other drugs recommended in the treatment of endometriosis are progestogens, but due to their side effects such as flatulence, depression and weight gain, some women are reluctant to use them. A convenient option for those ladies who are not concerned about their periods is a levonorgestrel-releasing intrauterine device. On the other hand, aromatase inhibitors are drugs that significantly reduce the severity of pain, but must be given in combination therapy. On the other hand, a drug with a proven effect on the inhibition of the progression of endometriosis are progesterone antagonists.
Surgical treatment of endometriosis
The scope of the surgery depends on the extent of the changes, pain and reproductive plans. Women who are planning to have children are offered sparing treatment, which consists in the complete removal of the lesions while preserving the genital organs. However, this treatment is associated with a high relapse rate. In the perimenopausal period, you should decide on a hysterectomy with removal of the appendages, i.e. radical treatment.
It is also possible to perform laparoscopic removal of isolated endometrial lesions, which is also associated with the risk of recurrence of the disease. It is most effective to combine surgical methods with pharmacotherapy.
Text: Lidia Banach