Speaker A
Endometriosis is a disorder that is characterized by endometrial tissue being found outside of the uterus. The most common locations are the ovaries, ligaments surrounding the uterus, and fallopian tubes. It is also commonly found in the Douglas or retrouterine pouch. However, it can be found in other parts of the pelvis like the vagina and cervix, the bowels or rectum, and even the bladder. In rarer cases, it can be found outside the pelvis in places such as the lungs, brain, skin, and has even been found in the nasal mucosa. Around 10 percent of women of reproductive age suffer from endometriosis, with a seven to ten times increased risk in those with first-degree relatives with the condition, and around 25 percent of these patients are asymptomatic. The average age at diagnosis is 28 years old. Endometriosis is typically underdiagnosed. A major symptom of it is recurring pelvic pain. Roughly 50 percent of women have pain with endometriosis, and most commonly it is a bilateral pain affecting the pelvis. It can also involve the lower back, rectal area, and the legs. Of the patients that have pain, around 70 percent of the time it is associated with menstruation. This can be explained due to the cyclical bleeding of the endometrial tissue, which can lead to inflammation and swelling. All the pain may come from adhesions. In this case, the pain is more likely to be constant throughout the menstrual cycle. Dysmenorrhea is often observed to worsen over time. Endometriosis is also associated with pain during sexual intercourse, which is termed dyspareunia. It is also associated with mittelschmerz, which is pain with ovulation. There can also be pain with urination or with bowel movements. An interesting point is that the degree of endometriosis does not correlate well with the pain. Some women have a small amount of endometriosis but have very severe pain, while others may have extensive disease and have little or no pain. Infertility is another major impact of endometriosis, and between 30 and 50 percent of women with endometriosis are infertile. Heavy or irregular menstrual periods are common in endometriosis, and when it is found in the thorax, it is termed thoracic endometriosis syndrome, which can manifest as catamenial, meaning associated with menstruation, pneumothorax, hemothorax, or hemoptysis, and is also associated with the development of pulmonary nodules. There is a close link with depression, which can manifest as chronic fatigue, and endometriosis is also linked with an increased risk of ovarian epithelioid and ovarian clear cell cancers, brain malignancy, and non-Hodgkin's lymphoma. It is not, however, associated with an increased risk of endometrial cancer. The exact cause for endometriosis is not known. Retrograde menstruation is one of the most commonly accepted theories for endometriosis. It is thought that some endometrial debris may flow backwards through the fallopian tubes into the peritoneal cavity and then attach itself onto the peritoneal surface. However, retrograde menstruation is very common, and endometriosis is only seen in some of these patients. Also, endometriosis has been described in patients without menstruation. Therefore, it is thought that there are other factors as well. Some of these are thought to be autoimmunity, as patients with endometriosis are more likely to have other autoimmune conditions like Graves' disease. The presence of toxic materials may also stimulate endometriosis, and the presence of stem cells that develop into endometriosis could explain the presence of ectopic endometrial tissue in distant sites such as the lung or the brain. As we said, endometriosis is an underdiagnosed condition. In the United States, there is a diagnostic delay of around 11 years, while in the UK it is around 8 years. The gold standard for diagnosis of endometriosis is laparoscopy for direct visualization of the lesions, and if lesions are not grossly visible, then biopsies are taken. These biopsies should show two out of three of endometrial-type stroma, endometrial epithelium with glands, or all evidence of chronic hemorrhage in the form of hemosiderin deposits. Imaging such as transvaginal ultrasound is commonly done before surgery due to it being non-invasive, and MRI is another non-invasive method of detecting endometriosis. Markers have been used in the past, such as CA125; however, studies have provided inconclusive results on the usefulness in the diagnosis of endometriosis. There is some evidence that suggests the use of combined oral contraceptives, regular exercise, and avoidance of alcohol and caffeine can help prevent endometriosis, but overall there is no definitive cure. The goals of management are to provide symptomatic relief, prevent disease progression, and to restore or preserve fertility. If the woman would like to have children, surgery is typically done laparoscopically and can include ablation or excision of endometrial tissue. However, ablation seems to have higher short-term recurrence rates when compared to excision. Most patients will develop adhesions after surgery, which can themselves lead to infertility, as well as predisposing to obstructions and making future surgeries more difficult. Medical management includes non-steroidal anti-inflammatory drugs, often as a first-line treatment, as the anti-inflammatory action works against the chronic inflammation seen in endometriosis and seems to have a beneficial effect in dysmenorrhea. Hormones like the combined oral contraceptive pill have been used to help reduce menstrual pain and are thought to help induce amenorrhea and suppress the activity of ectopic endometrial tissue. Progesterone agents are used as they counteract estrogen and inhibit the growth of the endometrium. Gonadotropin-releasing hormone modulators are also used, as they are thought to exhibit estrogen-modulating effects. Opioids are used in cases where the pain is not controlled with other analgesics. Overall, medical and surgical treatment were approximately equally effective for pain control, but surgery is more effective than medical therapy in managing infertility. Often, despite surgery, there are recurrences of endometriosis that are estimated to be around 30 percent in the case of dysmenorrhea within 12 months following laparoscopic surgery.
