WHAT IS ENDOMETRIOSIS?
Endometriosis is a pathological situation in which the cells of the endometrium - the internal mucous layer lining the uterus – starts growing outside the uterus and are transformed into pathological endometriotic tissue. The main problem here is that the endometrium, like the ovaries, changes depending on the day of the menstrual cycle: it gradually grows in thickness and is expelled monthly, causing bloody discharge - menstruation. If this process fails, endometriosis may develop.
There are three main types of endometriosis.
- The first is typical or superficial, when endometriotic tissue appears on the peritoneum - a thin membrane that lines the abdominal cavity, enveloping almost all internal organs.
- The second variant of endometriosis is cystic. In this case, the affected organ is the ovaries, in which the so-called endometriomas or endometroid cysts form (see the article “Cysts - from small to large”).
- In the third case, when the endometrium grows under the peritoneum into nearby organs - the intestines, bladder, postoperative scars – is the deep infiltrative endometriosis.
- Separately, very rare types of endometriosis can be distinguished - when the lungs or, for example, the brain are affected.
WHAT CAUSES ENDOMETRIOSIS?
It is still impossible to say with certainty whether the tissues that are found in endometriosis are the endometrium of the uterus, since the cellular composition is slightly different. But, perhaps, it depends on the location, and the endometrium, forming in an irregular place, changes under the influence of the external environment. The second possibility is that this, in fact, is other kind of tissue initially, and is just similar to the endometrium.
One of the theories as to what causes this disease is that all women experience a “reverse” blood flow through the fallopian tubes into the peritoneum during menstruation. And, under the influence of a certain set of factors - genetic predisposition, environmental influences, immunity - the cells mutate, change and become "endometriotic", creating foci of endometriosis.
Each type of endometriosis has its own developmental mechanism - pathogenesis. It is impossible to predict how endometriosis will develop in each particular patient in today's conditions.
WHAT ARE THE SYMPTOMS?
Only 10-15 percent of patients are susceptible to endometriosis, but given that in half of cases endometriosis does not cause any symptoms, the real figure can be much larger. If there are symptoms, the main clinical manifestations of endometriosis are infertility and pain, most often premenstrual and menstrual, (because of the connection between endometriosis and the menstrual cycle).
It can also cause chronic pelvic pains, pain during urination, during intercourse - depending on the location that is affected.
What causes infertility? It is due to chronic inflammation and toxic fluid that fills the ovaries and harms them. Moreover, because of chronic inflammation, adhesions are formed - “threads” of connective tissues, which “stick” the ovaries to the surrounding tissues, penetrate the surrounding organs, preventing the egg from reaching the fallopian tube. The adhesions can also disrupt the patency of the tubes themselves, for example, provoking a "stagnation" of fluid in them, called the hydrosalpinx.
In superficial endometriosis, a notable role is again played by the chronic inflammation, a change in the environment due to inflammatory factors, as a result of which the egg or fetus does not survive.
HOW TO FIND ENDOMETRIOSIS?
This process is lengthy: the time it takes from the onset of the first symptoms to a diagnosis, is on average 5-7 years. It is because the non-specificity of the symptoms - painful menstruation could be the only complaint a young girl, and it could be that it is labelled as a normal state. Identification of the causes requires a lot of time.
The method of diagnosis depends on the type of endometriosis.
- Superficial endometriosis can only be detected with laparoscopy - in which anesthetized patients have 3-4 small incisions in the anterior abdominal wall (no more than a centimeter in diameter) through which a camera and instruments are inserted into the abdominal cavity. This method is of particular importance, since it can not only detect foci of endometriosis, but it is also possible to immediately carry out surgical treatment. It is sometimes possible to make a diagnosis using magnetic resonance imaging (MRI), but this is a matter of very high qualification.
- In the case of cystic endometriosis - endometriomas, the main diagnostic method is ultrasonography (USG). This allows to determine the size of the cyst, the need to do additional examinations in case there is a suspicion of cancerous growths.
- With infiltrative endometriosis, the main diagnostic methods are USG and MRI. But, since a high qualification of a specialist is important to diagnose the endometriosis using USG, MRI will nevertheless be used to more accurately see the size and location of the endometrial site.
HOW TO TREAT ENDOMETRIOSIS?
There are two treatment options - medication and surgery.
In the first case, the goal is to try to get rid of the pain using medications. Since pain is most often associated with the menstrual cycle, the essence of this treatment is to “turn off” the organs responsible for the release of female hormones.
There are two groups of such drugs: the first is an analogue of gonadotropin-releasing hormones, for example, buserelin acetate acts at the level of the brain, stopping the production of hormones of the menstrual cycle, thus inducing an artificial menopause. The foci of hormone-dependent endometriosis are reduced, the symptoms disappear or become weaker.
But there are two cons - after the patients stop medicating, the manifestations of endometriosis gradually return, and along with the menopause its consequences can also be felt - osteoporosis, sweating flushes, weight gain, and so on. Therefore, such drugs are not recommended for a time span of more than six months.
The second option is continuous use hormonal contraception. Thus, the ovaries are “turned off”, and the growth of the endometrium is suppressed by continuous use of the drug. But in case the lesion is very large - this may not relieve the pain.
Therefore, the main method of treatment remains surgery. The most effective option is excision of the affected tissue. There is also the option of coagulation - cauterization of foci, but statistically, excision shows the best results. It is usually difficult to say how difficult the upcoming operation will be - it could simply be the excision of one lesion and dissection of adhesions, but it is possible that a surgery on the intestines, ureter or bladder will be necessary, in case the foci of endometriosis are found there.
Speaking of endometrioma, one should be careful with indications for surgery. If the cyst is less than 4 cm in diameter, it should be left alone, since during surgery there is a high risk of damage to the ovary with its ovarian reserves. Thereby, the opposite effect will be achieved - in the treatment of infertility, it will be gained. With this type of endometriosis, management tactics depend on the patient's complaints and reproductive plans.
If the operation is nevertheless necessary, then, before it is carried out, if the patient plans to carry out a pregnancy, the doctor can also take a blood test for the anti-Muller hormone - a sort of egg stock marker. And according to the results of such a test, the question of preliminary collection and storage of eggs before surgery will be decided - so that even though the ovary can be injured, the patient would retain her reproductive potential.
WHAT TO EXPECT AFTER THE TREATMENT?
If a patient decides to treat endometriosis with drugs, it is worth considering, firstly, that this does not rule out the return of the symptoms after the withdrawal from the drugs. Also, if a woman plans to “cure” endometriosis by pregnancy - it is important to understand that in this case there is no way to predict how the disease will behave - the symptoms may decrease, but it is possible that the disease will begin to progress.
Speaking of relapses of endometriosis – it all depends on the surgery. If the disease has returned, perhaps the doctor has not noticed some affected location or has been too careful trying to preserve the tissue during excision.
But usually, if the surgery has been successful, there is no recurrence of endometriosis.
