Endometriosis is distinguished by excruciating pain in the pelvic region, which frequently coincides with the onset of menstruation. However, it is also possible for it to take place regardless of the phase that the cycle is in. In many situations, the pain is so distressing that it completely interferes with normal day-to-day activities. Endometriosis is characterized by the proliferation of endometrial in locations other than the uterine cavity, such as the peritoneal cavity. This is the underlying cause of the condition.

What is endometriosis?

Endometriosis, which is an endometrium or wandering endometrium, is a disease that causes growth of the lining of thewomb(endometrium) outside the womb. You can imagine this as islets of the endometrium, scattered over various organs that are physiologically absent. The “islets” most often appear in the peritoneal cavity. They are less frequently found in other locations (e.g. in the vaginal vault).

As a result of inflammation, nodules and adhesions may form within them. Put simply, in women with a regularmenstrual cycle for three weeks, the mucosa grows in the uterus and then peels off during menstruation. However, in some women there is a situation where some of the endometrial cells, along with the menstrual blood, accidentally pass into the fallopian tubes and pass through them into the abdominal cavity. The cells can reach the ovaries, the peritoneum, the intestines, and even the bladder walls, staying there forever. This is what is known as endometriosis, which is the wandering lining of the womb. The problem of endometriosis concerns the vast majority of women – most often in the reproductive age. It is estimated that this disease occurs in 5-7% of women. In 75% of cases, it concerns young patients, aged 30-40. However, there have been isolated reports of endometriosis in men receiving hormone treatmentfor prostate cancer.

Why exactly in some women the cells that are displaced form endometriotic foci and not in others? In more than half of the cases, it is influenced by genetic and environmental factors.

The causes of endometriosis

The causes of endometriosis, although it has been known for over two hundred years, are not fully known. However, there are several theories about this. One of them says that during menstruation, especially heavy menstruation – menstrual blood flows back into the abdominal cavity (peritoneum) together with endometrial cells. There, endometrial cells settle and begin to live their own lives outside the uterine cavity.

Another theory is that endometriosis is genetic and is associated with hormonal and immune disorders. Endometriosis more often affects women whose mothers, sisters or grandmothers have also struggled with this condition.

Endometriosis – symptoms

The most characteristic symptom of endometriosis ispain, which occurs on a regular basis. It is most often located in the groin, lower abdomen, and sometimes even around the anus. Pain can be very bothersome and appear and disappear with or just before menstruation. In addition, the ailment of endometriosis makesmenstruation very painful, long and, unfortunately, abundant. Many patients complain ofpain during sexual intercourseand, in rare cases, ofintermenstrual spottingandtraces of blood in the stool and urine. Of course, a stray in the intestines or bladder can cause endometritispain during micturition and defecation.

The blood that collects in the course of endometriosis does not exit, and as a result,adhesions and chocolate cystsform . It should be noted that the symptoms of endometriosis are sometimes difficult to recognize, as this ailment can give rise to very different symptoms of varying severity.

In summary, the pain associated with endometriosis can be felt:

1. before, during or after menstruation,
2. duringovulation(ovulation),
3. when urinating,
4. during or after intercourse.

In addition to the pelvic area, it can also be found in the lower back.

In addition, other, additional symptoms of endometriosis may also appear:

1. diarrheaorconstipation(in some cases, they can occur at a certain stage of the menstrual cycle),
2. repeatedflatulence,
3. vaginal bleeding otherthan menstruation
4. feeling weak.

Often the most serious symptom of endometriosis isinfertility. Endometriosis has been shown to occur in one in three women who have difficulty conceiving. Of course, it should be emphasized that not every woman diagnosed with endometriosis will have problems with becoming pregnant in the future. This applies to approximately 30 percent. women. It is suspected that in some women, endometriosis outbreaks appear as a result of other causes of infertility, such as endocrine disorders.

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Endometriosis causes fertility problems in two ways: first, in women with endometriosis, adhesions are often observed in the abdomen and inside the uterus, so it is difficult to fertilize and reach the uterus. Secondly, endometriosis foci can secrete a substance and enzymes which, unfortunately, hinder the fertilization process and proper implantation of the egg.

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Consequences of endometriosis

Late diagnosis or improper treatment of endometriosis can lead to many complications, significantly worsening the comfort of everyday life. Treatment, both surgical and pharmacological, give a chance to stop the disease or at least slow its development. Endometriosis is progressive and can lead to gradual organ destruction. Chronic inflammation that irritates the peritoneum leads to the formation of scar tissue between organs, i.e. adhesions. They can cause irreversible anatomical changes. The most popular dysfunctions caused by adhesions include:

1. bowel obstruction
2. obstruction of the fallopian tubes,
3. intestinal motility disorders.

Endometriosis can also impair fertility, although there is no research available as to whether endometriosis is the direct cause of infertility or merely limits it. It is known for sure that fertility in women diagnosed with endometriosis is ten times lower than in healthy women.

In rare cases, there is a risk of an immediate threat to life. As a result of neglect, too late diagnosis, a woman may be forced, for example, to have astoma, remove the ovaries, fallopian tubes, and in extreme cases, a completehysterectomy.

That is why it is so important to diagnose endometriosis at an early stage and try to stop the disease progression and preserve fertility as early as possible.

Endometriosis diagnosis

Detecting endometriosis is not an easy task, although it can be suspected in any woman with very painful periods. The gynecological examination itself does not answer the question whether we are dealing with endometriosis.

When performinga gynecological examination, thedoctor can assess, first of all, the position, size and mobility of the uterus, ovaries, fallopian tubes, sacro-uterine ligament and the rectovaginal septum. The diagnosis of the last two elements should be performed with the simultaneous examination through the vagina and anus, i.e. inserting the index finger into the vagina and the middle finger into the rectum. If the test is performed during menstruation, the possibility of detecting endometriosis foci is significantly increased.

The doctor may also performan ultrasound imaging,which, however, does not always dispel doubts.Ultrasound imagingperformed through the vagina or rectum is the basic diagnostic examination (gynecological ultrasoundcan be purchased at Medonet Market). The endometrial cysts located in the ovary show a very characteristic picture during the ultrasound examination. They are distinguished by thick and fibrous walls, while their interior is filled with thick, hemolyzed blood. The indications for an ultrasound examination through the rectum are bowel complaints.

In cases of suspicion of changes in the large intestine or focal changes in the posterior vaginal fornix, the doctor will most likely decide to perform an ultrasound scan through the anus. Magnetic resonance imaging is also a useful imaging test. The results of the examination helps your doctor to map the existing lesions before starting surgical treatment.

For the final diagnosis, it is necessary to performlaparoscopy, during which the gynecologist can directly examine the female reproductive organ and take specimens for histopathological examination. Duringlaparoscopy,it is possible to remove all or part of the implants. Given that the symptoms of endometriosis are very non-specific, only 1 in 4 women will be diagnosed correctly right away. If endometriosis is suspected, the doctor also orders ablood test – the level of the CA-125 marker.In some cases, computed tomographyis also helpful .

The Polish Gynecological Society recommends thatlaparoscopy should be performed primarily in patientswho:

1. struggle with dyspareunia, painful menstruation and chronic pain,
2. struggle with the deterioration of their quality of life,
3. do not respond to drug treatment or cannot use this form of treatment,
4. are diagnosed for the presence of painful nodules in the sacro-uterine ligaments;
5. are diagnosed towards lumpy lesions;
6. they are infertile, and diagnostic examinations did not reveal any pathologies or deviations from the norm.

Colonoscopyis used less frequently in the diagnosis of endometriosis . This examination is recommended in cases of deeply infiltrating endometriosis, especially in the area of ​​the bladder and large intestine. In such a situation, cystoscopy may also be indicated.

The American Society for Reproductive Medicine (ASRM) has classified endometriosis according to several grades:

1st degree (minimal)– endometriosis foci are small, less than 5 mm; non-vascularized adhesions are visible in the ovaries and fallopian tubes;

2nd degree (benign)– the changes occurring reach a diameter of more than 5 mm, and the adhesions are located in the ovaries and fallopian tubes; endometrial changes can also be seen in the recto-uterine cavity; in addition, chocolate (endometrial) cysts appear in women;

3rd degree (moderate)– the sacro-uterine ligaments adhere to the fallopian tubes and ovaries; the occurrence of adhesions is also observed in the hyphae of the fallopian tubes, and the foci of endometriosis are present in the adhesions of the ovaries;

Stage IV (severe)– this is the most severe form of endometriosis, in which the uterus is immobile, attached to the back flexion and into the intestines, or displaced backwards. The intestines, which are in adhesions with the peritoneum of the recto-uterine cavity, also look unattractive; changes in endometriosis are also found in the vagina, appendix, bladder and cervix.

Endometriosis – treatment

In the treatment of endometriosis, pharmacological, surgical or combination methods are used.Choosing the right method of treatment depends on the effectiveness, tolerability and cost of the therapy. The woman’s plans for pregnancy and motherhood are also important information for the doctor.

Drug treatment of endometriosis

Patients are prescribed contraceptives, gestagens and drugs that reduce the secretion of gonadotropin by the pituitary gland and estrogens by the ovaries, whose task is to inhibit the growth of the mucosa in the uterus and endometriosis foci. Although these methods are aimed at alleviating the symptoms and limiting the development of the disease, they also have a contraceptive effect, which, unfortunately, does not improve the patient’s fertility after the end of the treatment. According to some doctors, treatment of endometriosis with contraceptives is pointless as a woman’s reproductive time is running out. As a consequence, a woman’s fertility does not improve after treatment, and the older a woman gets, the more difficult it is to get pregnant. Drugs for the treatment of endometriosis can be divided into:

1. oral contraceptive pills– these are measures that have been used for many years. They reduce pain during menstruation, as well as that caused by endometriosis. Oralcontraceptive pillsare usually selected at the start of therapy when endometriosis is suspected. The risk of side effects is the same as with hormonal contraception;
2. progestogens– these are agents that inhibit the growth of endometriotic implants. Taking them leads to the disappearance of these implants. Progestogens are taken orally or intramuscularly. They can also be used in the form of intrauterine systems that release the hormone. This solution is especially recommended for women who struggle with heavy and painful periods. Progestogens can contribute to weight gain, water retention, depressed mood and irregular bleeding.
3. Danazol– is an agent that inhibits the synthesis and release of gonadotropins. It also takes part in the synthesis of ovarian hormones. The analgesic effect of danazol is comparable to that of other drugs of this type. It is worth noting that danazol is used less and less because it is androgenic and causesacne, weight gain andhirsutism. Other side effects of this medication include hot flushes, vaginal dryness and emotional lability.
4. gonadoliberin analogues– these are agents that inhibit the secretion of gonadotrophins by the pituitary gland. Until recently, analogues were used as initial therapy to treat the symptoms of endometriosis, i.e. severe pain. Gonadoliberin analogues are taken intramuscularly, subcutaneously and intranasally. Therapy with this drug lasts about 6 months. The side effect caused by the analogs relates to hypoestrogenism, including the risk of developingosteoporosis. Many doctors decide not to treat with this agent due to the relatively high price of analogues;
5. non-steroidal anti-inflammatory drugs– these are measures that are used to reduce the pain caused by endometriosis. Their advantages are low side effects, low price and high availability;
6. aromatase inhibitors– this is an enzyme that plays an important role in the production of estrogens and gestagens. The effectiveness of the inhibitors has been confirmed in several clinical trials. Their use is supported by the fact that they have no effect on the reduction of bone mineral density.

ATTENTION!

Despite the wide range of treatments available, none of these methods completely cure endometriosis. Additionally, all of the above drugs adversely affect the chance of becoming pregnant. Therefore, hormone therapy in women planning pregnancy is usually postponed for the next months.

Surgical treatment of endometriosis

Surgical treatment is most often carried out using laparoscopy. This method also has diagnostic and therapeutic properties, as it helps in making a diagnosis and enables the removal of lesions. Usually, an indication for removal is endometrial cysts, the diameter of which exceeds 3 cm. It happens that the procedure of enucleation ends with the destruction of normal ovarian tissue. In addition, during laparoscopy, it is possible to remove adhesions that make it difficult to conceive. Within six months after the procedure, a woman’s fertility improves significantly, so there is a greater chance of conception. In the course of surgical treatment, conservative and radical surgical treatment are distinguished.

1. Conservative surgical treatment– this type of treatment is undertaken to remove disease foci and restore the proper functioning of the pelvic organs. Conservative surgery should reduce pain, improve fertility, and eliminate the risk of endometriosis recurrence. It is worth noting that the complete removal of endometriosis is very difficult and requires the experience of a doctor and specialized equipment. If the endometriosis lesions are not completely removed, symptoms will still persist and the risk of relapse will increase significantly. Conservative surgical treatment is an option for infertile women with low or medium intensity of the disease. This mainly applies to the removal of cysts larger than 3 cm in diameter. In the case of conservative surgical treatment, laparoscopy is used, because it is a safe, minimally invasive and accepted method. Performing laparoscopy is associated with fewer complications and a much shorter stay in a medical facility. Complications that may occur after laparoscopy are damage to the intestines, bladder or large vessels.
2. Radical surgical treatment– is used in particularly difficult cases, when pharmacotherapy and conservative surgical treatment turn out to be ineffective. Radical surgical treatment is also used in women who are not planning a pregnancy. This type of treatment involves the removal of the uterus and ovaries. Such a procedure induces surgical menopause, but does not lead to complete recovery in all operated patients. If the decision is made to preserve the ovaries, the risk of another operation is greatly increased. The operation to remove the uterus with appendages should be carried out by an experienced doctor in a specialized medical institution.

After surgical treatment, recovery and daily fitness are quite individual. Women who are not planning pregnancy focus on returning to their daily duties and work. Recurrences of endometriosis are quite frequent, therefore pharmacological therapy is often repeated. A second operation is much less frequent. On the other hand, women who plan to become pregnant should start their efforts immediately after the end of surgical treatment. If the attempts are unsuccessful, the doctor will probably suggest in vitro fertilization.

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Endometriosis and in vitro

If the woman still cannot become pregnant after surgery, other treatments are being considered. When nothing helps, infertile women use thetechnique of insemination, i.e. assisted reproduction, orin vitro.The method is selected based on the patient’s age and the duration of efforts for a child. The older the patient is, the smaller her ovarian reserve is. On the other hand, younger women with patent fallopian tubes, short duration of infertility and a partner with appropriate sperm parameters undergo diagnostics and possibly laparoscopic treatment, and then insemination in the natural cycle. In vitro fertilization is only used when all other methods have failed.

IMPORTANT!

Endometriosis and diet

Recently, a lot of attention in the treatment of endometriosis has been focused on proper diet and exercise. By including more fruits and vegetables in the menu and less meat, you can minimize the risk of developing endometriosis. Fruits and vegetables contain antioxidants: vitamins A, C, E and beta carotene (yellow and red vegetables and fruits).

The exclusion of trans fatsfrom the diet , which intensifies the effect of pro-inflammatory prostaglandins, has a positive effect on improving health . Trans fats are naturally contained in meat and milk, but the most dangerous are those found in margarine. It is also worth avoiding fried foods, because as a result of high temperature and oxygen, the structure of healthy fats is damaged and transformed into harmful fats. In turn, it is recommended to consume omega-3 and omega-6 fatty acids, which are found in large amounts, e.g. in fish.

Some research studies have shown that women with endometriosis who eliminate wheat from their diets experience significantly less pain. Restoring wheat to the menu resulted in a recurrence of the ailments.Some say that glutenplays a major role in the development of endometriosis .

Finally, physical activity should be mentioned. Active women who regularly exercise are less exposed to the risk of adhesions and less likely to complain of pain. In addition, with regular activity, the organs work better, as does the metabolism.

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