Endometriosis is one of the most incomprehensible gynecological diseases, and when doctors themselves do not fully understand something, the patient is doubly difficult. After analyzing quite a lot of recent publications on the subject of this disease, I came to the conclusion that there has been no progress over the past 10 years. Unfortunately, most of the articles are just confused by the lack of prospects for creating new approaches to the treatment of endometriosis and nothing more.
Endometriosis is one of the most obscure diseases.
Let’s try to understand this rather incomprehensible problem together.
WHAT IS ENDOMETRIOSIS?
Endometriosis is a chronic disease in which the tissue of the uterine mucosa (endometrium) is located in addition to the uterine cavity in other places of the body where it should not be. Let me explain: the uterine cavity is lined from the inside with a mucous membrane called the endometrium (the name is similar to the name of the disease). It is this mucosa that is rejected in women during menstruation, so that a new one grows in the next cycle. So, if this mucous membrane appears in any other place except the uterus, it will already be called the disease “endometriosis”.
What types of endometriosis are there? There are three main areas where this mucous membrane can appear: on the peritoneum of the pelvis, tubes, ovaries, in other words, outside the uterus in the abdominal cavity – this form of endometriosis is called “external genital endometriosis”. A separate type of external genital endometriosis is endometrioid ovarian cysts. In this case, a cyst appears in the ovary, lined from the inside with a slightly modified endometrium, which is also cyclically rejected, only not outwards, as it happens in the uterus during menstruation, but inside itself. That is, the growth of this cyst is due to the accumulation of menstrual secretions in it, which are concentrated, and therefore the content of such a cyst is also called “chocolate”. Yes, a very important conceptual point: the mucous membrane of the uterus, located in the wrong place for it, also continues to respond to hormonal fluctuations during the cycle, and this is manifested by “miniature menstruation”. If the mucous membrane seems to grow into the wall of the uterus, like the roots of seedlings through a cardboard box where it was grown, with the formation of foci and nodes that increase the uterus in size, this endometriosis is called adenomyosis. If fragments of the uterine mucosa are found outside the genitals (on the skin in the area of the postoperative scar, in the lungs, the eye chamber, kidneys or bladder, etc.), this endometriosis is called extragenital; fortunately, it is extremely rare.
Endometriosis affects from 5 to 10 % of women in the world, and up to 50 % of those who suffer from infertility.
How common is endometriosis? According to various authors, endometriosis affects from 5 to 10% of women in the General population and 50 % of women who treat infertility.
Why does this disease occur and what should I do to prevent it from developing? There are three theories, they are quite convincing, but none of them could be proved. Thus, we must admit that the reasons are unknown. There are no risk factors. Simply put, you will either have endometriosis, or not, and if you do, it will occur in a light and almost invisible form for you, or will create a serious problem for life and reproduction. In other words, it is most likely that there are genetic causes that are influenced by external factors.
The causes of endometriosis are still unclear. Most likely, the development of this disease is influenced by genetics and the combination of adverse external factors.
How can endometriosis manifest itself? It all depends on the form of the disease and its severity. Let’s start with external genital endometriosis. The most common complaint is abdominal pain of varying duration and intensity, pain during ovulation, during sexual life, painful menstruation. Agree, the symptom is quite non-specific, because similar pain can occur in the presence of other causes. The cause of pain in endometriosis is the same “miniature menstruation” that occurs in small foci located on the peritoneum of the pelvis, and the following inflammatory reaction. In particular, this is why endometriosis is also called a chronic inflammatory disease. In response to any inflammation in the abdominal cavity, there are adhesions that can only increase pain, and also lead to the formation of a tubal factor of infertility, that is, mechanically violate their patency. This, by the way, is one of the mechanisms of infertility on the background of endometriosis, the second possible mechanism is a change in the immune balance in the abdominal cavity, which negatively affects sperm and eggs.
Other mechanisms are assumed, but all of them are not reliably proven. An extremely aggressive form of external endometriosis is a situation when it begins to grow into the walls of organs adjacent to the uterus – the rectum, bladder, and vaginal wall. Then additional symptoms may be added to the rather pronounced pain: blood and pain during defecation or urination, the formation of outgrowths in the posterior arch of the vagina (“spines”). Endometrioid cysts are often asymptomatic even with large sizes, in fact, this is their main insidiousness. The main problem with these cysts is that they compress the healthy part of the ovary during growth, replacing almost the entire organ, which can lead to the loss of the ovary. Adenomyosis is characterized by very painful and abundant menstruation, as well as brownish “smearing” discharge before or after menstruation (may be normal, the symptom is non-specific). The uterus often increases in size. With extragenital endometriosis, there are bloody discharge in the organs where it occurs, for example, blood when coughing, “blood tears”, blood in the urine. Often these secretions are cyclical, that is, they coincide with the period of menstruation. On the skin, endometriosis can manifest as a painful infiltration.
The main symptom of endometriosis is pain.
How to diagnose endometriosis? Individual forms of endometriosis are very easy to diagnose. For example, an endometrioid ovarian cyst has a very characteristic appearance during ultrasound, and there are almost no difficulties. Adenomyosis (in my understanding) with ultrasound is also easy to put, but here you need to make a comment. The fact is that there is a so-called “ultrasonic adenomyosis”, that is, the criteria for making this diagnosis are detected during ultrasound, but the patient does not have clinical manifestations and will never have them. Therefore, if you meet such a diagnosis in your conclusion, and your monthly periods are painless and not plentiful, you can not attach any serious importance to this. In some cases, adenomyosis can not be distinguished by ultrasound from another disease – uterine fibroids. Then the objective method of diagnosis is pelvic MRI. It is most difficult to diagnose “external genital endometriosis”, since its symptoms are non-specific. With an aggressive course, when it sprouts into the walls, it is easier – even with a simple examination on the chair, you can detect “spikes” in the posterior arch of the vagina, but most often we can only suspect such a diagnosis. The” gold standard ” diagnosis of external endometriosis is laparoscopy, alas. Therefore, there are difficulties in making such a diagnosis. Complaints of abdominal pain and painful menstruation are probably one of the most frequent in gynecology, but you can’t blame everything on endometriosis alone. Since you can only prove the presence of endometriosis by laparoscopy, that is, surgery, it is very convenient to tell the patient that her pain is a manifestation of endometriosis, and especially not to go into the search for the true cause. It is this situation with the diagnosis that gives rise to various manipulations.
External endometriosis can only be diagnosed by laparoscopy.
How to treat endometriosis and is it worth it in all cases? With the treatment of endometriosis, everything is very sad. The concept of treatment has not changed for many years, and it is, alas, quite primitive. If the disease has moderate manifestations and there are no reproductive tasks-to fight the symptoms before menopause, and after menopause, the disease stops on its own. It is not possible to completely cure endometriosis before menopause, since the disease is prone to relapse as soon as it is no longer suppressed. Now specifically on the main forms of endometriosis.
The concept of endometriosis treatment has not changed for more than 10 years and includes wait-and-see tactics, suppression or removal-depending on the form.
Endometrioid ovarian cysts-up to 3 cm, do not need to be removed, you can restrain their growth by taking contraceptives, preferably in a continuous mode, or a visa. You can get pregnant with such cysts, it is not dangerous. Cysts larger than 3 cm should be removed by laparoscopic access. It is important that after removal of the cyst, you must either become pregnant or start taking visanna (sometimes, depending on the severity of concomitant external endometriosis, you can prescribe a course of drugs that create an artificial menopause before visanna). If nothing is done, the risk of relapse of such cysts is extremely high. “Well, take this visanne to menopause?» Unfortunately, Yes, there are no other options. Instead of visanna, you can prescribe contraceptives, this is also an option, but the latest data shows that visanna is superior to contraceptives in effectiveness. Important: removal of endometrioid cysts from the ovary leads to a decrease in its reserve, that is, shortens its service life. Actually, this is why small cysts do not need to be removed, since the benefits of this are much less than the harm caused by surgical removal.
External genital endometriosis. Treatment will be determined by the clinical situation. If you have severe abdominal pain with intercourse, painful menstruation, and oral contraceptives or visanne does not remove these feelings, you will be a laparoscopy, during which the coagulated lesions of endometriosis and after surgery was prescribed a course of treatment with drugs that temporarily will take you into menopause and then have to continuously make visanne. If contraceptives and visanne right – this will be your main treatment, which of course will not cure anything, but will improve the quality of life. The following situation: you have been diagnosed with infertility, all other causes are excluded, there are symptoms of endometriosis – then laparoscopy and coagulation of endometriosis foci will be directed to the treatment of infertility. The treatment will have a temporary effect.
Treatment for external genital endometriosis is reduced to improving the quality of life of the patient, that is, to alleviate the condition. But there will be no real recovery.
Adenomyosis. Let me remind you that asymptomatic (delivered only by ultrasound) adenomyosis does not need treatment. Adenomyosis, which manifests itself with abundant painful menstruation, like other forms of endometriosis, is not treated very effectively. The surgical method is impractical. EMA is, in fact, the most effective treatment for endometriosis, but its effectiveness reaches only 85 %. Medical treatment consists of temporary introduction of the patient into an artificial menopause with the subsequent maintenance of the achieved effect by introducing an intrauterine hormone spiral “Mirena” or taking the same visanna. And all this-until menopause and continuously, otherwise relapse. There is still debate about the impact of adenomyosis on the ability to get pregnant. There are no unambiguous data, in fact, this is the situation with all studies on endometriosis.
The most effective method of treating adenomyosis is EMA.
Extragenital forms of endometriosis, as I have already said, are extremely rare and are treated with surgical removal of foci.
The prospects. The only hope for a breakthrough in the treatment of this disease rests on the drug esmia (a selective progesterone receptor blocker), which is now used to treat uterine fibroids. There are good preliminary results. As they say, we are waiting.
As you can see, we are not yet able to cope with endometriosis, and this is understandable, since we have not progressed in understanding the causes of this disease and its nature. It is convenient to blame a lot of gynecological symptoms and causes of infertility on endometriosis, so if there was no endometriosis, it would just have to be invented. You should not think about what you did wrong and why you developed endometriosis. Once again, it either happens to you or not, that is, 90 % of women may not even think about this disease. Those who still had to deal with endometriosis will have to accept the fact that before the menopause, you will not be able to relax completely, and you will have to accept some type of therapy.