Endometriosis is a hormone-dependent disorder characterized by an overgrowth of endometrial cells affecting organs outside the uterus which are not normally involved. These are most commonly the ovaries, the peritoneum, the muscle layer of the uterus, the cervix, the intestines, and the bladder. In rare cases, endometrial cells are found at a distance from the uterus, like in the lungs, eyes, skin, etc.
Endometriosis is usually diagnosed in women aged 30–45. Approximately 10% of women of reproductive age suffer from endometriosis. But the number is much higher, because in many women the disease is asymptomatic, so they do not seek medical attention and the disease goes unrecognized. Sometimes the disease is also found in adolescents, less often in menopausal women.
Endometriosis develops more often in women who have not given birth, who have been exposed to estrogen for a long time, who had early onset of menstruation (before the age of 11–13), in cases of delayed menopause and menstrual cycle disorders, in thin women taller than 170 cm.
Conversely, childbirth, lactation, the onset of menstruation after the age of 14 are protective factors against endometriosis. There is evidence that endometriosis is less common in women who take sufficient amounts of omega-3 fatty acids.
Genetic factors, disorders of the immune and neuroendocrine systems also play their role in the occurrence and progression of the disease. But so far there is no exact answer.
Types of Endometriosis
Endometriosis occurs in two main types, depending on their causes and manifestations:
It affects the internal genital organs ‒ the uterus, the fallopian tubes, the ovaries, the vagina. As a consequence of the presence of a chronic inflammatory process (endometritis of any nature), abortions, trauma, the presence of an intrauterine device or even spontaneously endometrial cells begin to grow into the muscular layer of the uterus. There are also two subtypes of it:
- Genitalis externa (affects only the ovaries and peritoneum of the small pelvis)
- Interna (adenomyosis or endometriosis of the uterus; it grows into the muscular layer, leading to an increase in the uterine body, often accompanied by myoma)
Foci of endometriosis occur in the pelvic organs, abdomen, lungs, intestines, skin, etc. During periods, blood with rejected endometrial cells for various reasons gets first into the fallopian tubes and then into the abdominal cavity. The endometrial cells attach to the surface of the peritoneum, gradually increase in number, menstruate, and then spread further through the body. There have been cases of a combination of both genital and extragenital endometriosis.
Doctors also use the classification of endometriosis according to the degree of damage and how deep the process penetrates into the tissues of the affected organ. Four stages are distinguished, with Stage I being minimal endometriosis, and Stage IV being severe endometriosis which is difficult to cure.
Symptoms of Endometriosis
Sometimes endometriosis does not manifest itself in any way, and it can be found only during a routine examination. But most often there are certain signs of the pathology. The symptomatology is very diverse, but there are common complaints:
- Pelvic pain. The pain is usually of a cyclical nature (appears or worsens before menstruation and lasts until the third day of the cycle), but it may also be persistent. Patients often describe it as dull, throbbing, and acute. This is the most common symptom. It appears in more than half of the patients.
- Heavy menstrual flow (menorrhagia).
- Dark brown discharge which appears a few days before menstruation or a few days after it ends.
- Pain during sexual intercourse (dyspareunia).
- Pain when emptying the intestines or the bladder.
Although infertility can rather be considered as a consequence.
When a woman is diagnosed with endometriosis, the choice of therapy depends on the severity of the pathology, its localization and the degree of symptoms. Many factors are taken into account ‒ the patient’s age, the presence of children, the desire for pregnancy, etc.
The treatment of endometriosis is aimed not only at easing the symptoms and eliminating the active process, but also at treating the complications of the pathology. For example, adhesions, ovarian cysts, pain that arises during defecation.
Today’s medicine uses the following ways to treat endometriosis:
- conservative (the use of hormonal contraceptives, medications that relieve inflammation and pain);
- surgical (performing laparoscopic or laparotomic surgical intervention to excise the foci of endometrial tissue growth with maximum preservation of the affected organ);
- surgical radical (complete removal of the organs of the reproductive system);
- combined (a combination of surgical techniques and hormonal treatment).
Conservative treatment is used when it is necessary to preserve the childbearing function of a woman at a young age or premenopause and when preparing for surgical treatment. The treatment involves two approaches ‒ pain management (analgesics, NSAIDs) and suppression of pathological foci with hormonal medications. The most widely used drugs are the following:
- Progestins (gestagens)
They are taken in a course of 6 to 8 months with any type and stage of endometriosis. They contribute to the normalization of endometrial secretion, slow down its growth and reduce menstrual bleeding, up to its complete absence. These are Dydrogesterone, Progesterone, Norethindrone. The possible side effects include depression, intermenstrual bloody discharge, pain in the mammary glands.
- Monophasic Combined Oral Contraceptives (COCs)
Oral contraceptives from Canadian pharmacy completely block the cyclic mechanisms in the female body, which prevents the growth and subsequent rejection of the endometrium and menstrual bleeding. This leads to complete or almost complete elimination of the manifestations of endometriosis. These are Alesse, Min-Ovral, Seasonale, Seasonique, Ortho, Yasmin and others. The use of COCs can cause headaches, depression, insomnia, a rise in blood pressure, and low libido.
- Gonadotropin-releasing hormone agonists, hormone releasing systems: vaginal and transdermal combined hormonal contraceptives, subcutaneous and intramuscular progestin depo-forms, levonorgestrel-releasing intrauterine system (LNG-IUS)They are used when COCs and gestagens are ineffective or before laparoscopic surgery for endometriosis.
Gonadotropin-releasing hormone agonists are taken once a month and are “big guns” in hormonal therapy. They are indicated for stages III and IV of endometriosis. They block the production of specific releasing factors in the hypothalamus, which prevents the further production of sex hormones according to the female cycle. These are Leuprolide acetate, Goserelin and others. These medications can cause hot flushes, low libido, vaginal dryness, menopause symptoms, osteoporosis, headaches and muscle pain.
Surgical treatment is the choice when the disease continues to evolve, or with intolerance to certain medications. In this case, surgery is performed if the foci of endometriosis are more than 3 cm in diameter and the nearby organs are affected. Currently, organ preserving surgery which avoids removal of the uterus and appendages is increasingly preferred. The main objective of surgical treatment of endometriosis today is to remove the foci and restore the functionality of the female reproductive system as much as possible.
Risks of Endometriosis
The development of complications of this disease is closely related to its manifestations and symptoms. The most serious consequences of endometriosis are:
- Damage to the central nervous system
- Malignization of endometriosis foci
If a pregnancy does occur in the presence of endometriosis, it may be complicated by the threat of miscarriage, abnormal attachment of the placenta and fetal hypoxia. Adhesions may lead to the development of an ectopic pregnancy. This is why it is important to treat endometriosis and start it as early as possible.