Endometriosis

Endometriosis is a disease in which some parts of the endometrium can be found outside the uterine cavity. Symptoms include painful menstrual bleeding, prolonged pain in the lower abdomen, painful sexual intercourse and fertility problems. Endometriosis is the most frequent gynecological disorder during a female reproductive age. It is seen in 20 – 50% of infertile women and in 50% of women with pelvic pain.

The cause of endometriosis has yet to be determined. Several factors usually contribute to the formation of endometriosis – genetic, immunologic and hormonal. Under normal circumstances, hormonally changed endometrium flushes out from the uterine cavity during menstrual bleeding. Small parts of the endometrium are then passed through the fallopian tubes to the abdominal cavity. One of the theories assessing the formation of endometriosis suggests that the same hormonal process that takes place in the endometrium also occurs to the nested (implanted) parts of the endometrium in the abdominal cavity and pelvis.

Another theory presumes that some cells in the abdominal cavity change into cells resembling endometrium after repeated inflammations in the woman´s small pelvis or as a reaction to the higher blood estrogen levels (female sex hormones).

One of the other theories – immunologic – suggests the presence of endometrial antibodies in a female body or lower cell immunity. As a result, the woman’s immunity system does not react to the endometrial bearings, does not destroy them and facilitates nesting (implantation) of the endometrium or its transition into a different cell structure (metaplasia).

Endometriosis causes infertility by creating adhesions in the woman´s pelvic area. The adhesions restrict contact between the internal reproductive organs and cause changes in the hormonal, immunologic and biochemical processes responsible for merging of embryonic cells, early embryonic development and the transport of an embryo into the uterine cavity.

According to the location there are 4 basic types of endometriosis:

Peritoneal endometriosis – ectopic tissue in the pelvis.
Colored stains several millimeters in size are usually found on the perineum during laparoscopy. Color of the stains differs based on the stage of development of the endometrial lining. Initially, they are red in color and go through the same hormonal development as the uterine lining. This leads to a local inflammation in the area of the polyps, which close themselves as the time passes. In the closed polyps, the secreted tissue is accumulated, which makes them larger and changes its color to blue. Vascular supply in the polyps gradually disappears and they transform into scars. This leads to the final stage – white endometriosis. The scarring process in the area near the fibroids can sometimes form round defects (openings) on the peritoneum.

Ovarian endometriosis – fibroids on the ovaries .
This type is characterized by colored fibroids on the surface of the ovaries, which can nest themselves deep down in the ovary and form a cyst up to a few centimeters in size. The cyst is known as endometrium or an endometrial cyst. It contains brownish liquid, which is why it is often referred to as a chocolate cyst.

Endometriosis of the rectovaginal septum – endometriosis at the thin structure separating the vagina and the rectum.
The presence of tough nodules is typical for this type of endometriosis. Nodules are formed by excessive production of smooth muscle fibers and ligaments in the area near the endometrial glands. This type is also frequently referred to as deep endometriosis because it affects not only the above mentioned septum, but also the ligaments between the uterus and the pelvic bones. Nodules can also form in the muscles of the pelvic organs. This endometriosis is only minimally affected by changes during menstrual cycle and it is manifested by a significant and prolonged pain.

Adenomyosis – adhesions inside the uterine muscles.
This type usually does not occur as an isolated manifestation. Often, it is combined with peritoneal endometriosis, often uterine myomas – muscular nodules on the uterus. Symptoms include increased bleeding, enlarged and painful uterus and some additional symptoms typical for endometriosis, such as painful menstruation, pelvic pain and pain during a sexual intercourse.

Diagnosis of endometriosis can be determined based on the analysis of the patient’s subjective problems or by clinical examination combined with ultrasound imaging. However, the diagnosis is most often determined only after laparoscopy.

Treatment for Endometriosis

Conservative – hormonal treatment
This treatment has a high success rate (75 – 95%), but 25 – 50% patients can experience recurrence of endometriosis. Response to treatment is individual and, to a certain extent, depends on laparoscopic and histologic findings. The conservative treatment works best for peritoneal adhesions, it is less effective for ovarian adhesions and essentially non-effective for rectovaginal endometriosis.

Medications used in hormonal treatment block the function of the hormones from the main hormonal control organ – the hypophysis. They lower the levels of the ovarian hormone estrogen, which prevents the periodic changes of the endometrium. Treated endometrial adhesions get smaller and eventually completely disappear. The treatment takes 3 – 6 months. Used medications are usually applied subcutaneously or by a simple intramuscular injection (DIPHERELINE, DECAPEPTYL, ZOLADEX). Side effects of this treatment include temporal absence of menstruation, depression, mood swings, hot flashes and sleeping disturbances; however, they only last for the duration of the treatment.

Hormonal contraception is another type of hormonal treatment. It lowers hormonal stimulation of the endometrial lining, but it is not as effective as the above mentioned treatment.

Surgical Treatment
If endometriosis is diagnosed during laparoscopy, then surgical removal of the adhesions and the cysts-endometriomas-is an important part of the treatment. Surgical reduction of the adhesions enhances the effectiveness of the hormonal treatment.

If infertility is the main problem, the treatment is individually based. Treatment then utilizes assisted reproduction methods often combined with hormonal and surgical treatment.