Endometriosis – Key points , Prof. Alaa Mosbah

Endometriosis – Key points

–Definition:

It is the presence of endometrial tissue outside of the uterine cavity.

-Incidence:

Endometriosis affects up to 10 percent of reproductive-aged women. It is more common in women with pelvic pain or infertility 70 to 90 percent and 21 to 40 percent, respectively.

-Risk Factors for endometriosis:

Early menarche ,First-degree relative with endometriosis ,Late menopause ,Low body mass index, Müllerian anomalies , Nulliparity ,Prolonged menstruation (> five days) ,Shorter lactation intervals ,Shorter menstrual cycles (< 28 days)  and White race (compared with black race)

-Sites of occurrence of endometriosis:

The common sites of endometriosis are the ovaries, fallopian tubes, pelvic peritoneum, D.P, uterovesical pouch and uterosacral ligaments (alternatively called the "pelvic" site), whereas the atypical sites of endometriosis include the gastrointestinal tract, urinary tract, soft tissues, and chest (alternatively called the "extra-pelvic".

-Causes of endometriosis: no cause discovered yet

Theories of What Causes Endometriosis:

      .The retrograde menstruation theory (transtubal migration theory) suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows.

    .One theory suggests that endometrial tissue is distributed from the uterus to other parts of the body through the lymph or blood systems.

    .A genetic theory suggests that certain families have predisposing factors for the disease.

    .Surgical transplantation has also been cited in many cases where endometriosis is found in abdominal scars, although it has also been found in such scars when accidental implantation seems unlikely.

    .Another theory suggests that remnants of tissue from when the woman was an embryo may later develop into endo or that some adult tissues retain the ability they had in the embryo stage to transform under certain circumstances.

    . Environmental toxins such as dioxin and PCBs, which act like hormones in the body and damage the immune system, can cause endometriosis. Dioxins are highly toxic chemicals which come from the production and use of pesticides and herbicides.

-Diagnosis:

Some women with endometriosis are asymptomatic, whereas others present with symptoms such as chronic pelvic pain, dysmenorrhea, dyspareunia, and decreased fertility. Hematuria and dysuria with bladder affection. Dyskasia with rectal lesions. Chest pain and hemoptysis with lung affection. Ultrasonography and MRI can diagnose edometrioma and other deep pelvic lesions. Laparoscopy is the gold standard for diagnosis. The cancer antigen 125 (CA125) level is often elevated in women with endometriosis, but its specificity for the disease is low.

- Biologic mechanisms that might Link endometriosis and infertility:

• Distorted pelvic anatomy

• Altered peritoneal function

• Altered hormonal & cell-mediated function

• Endocrine and ovulatory abnormalities

• Abnormal uterotubal transport

• Impaired implantation

• Oocyte and embryo quality 

-Staging of endometriosis:

According to the American Society for Reproductive Medicine (ASRM),

.Minimal endometriosis also called stage 1,  (1-5 points) endometriosis, and is characterized by isolated implants and no significant adhesions.

.Mild endometriosis ,stage 2, (6-15 points) is characterized by superficial implants that measure less than 5 cm in diameter without significant adhesions.

.Moderate endometriosis ,stage 3, (16-40 points)  involves multiple deep implants, small cysts on one or both ovaries, and the presence of flimsy adhesions.

.Severe endometriosis ,stage 4 , (>40 points) consists of multiple deep implants, large cysts on one or both ovaries, and thick adhesions.

-Treatment:

.Treatment depend on the age of patient , desire for fertility , presence of sufficient number of children and stage of endometriosis.

.Treatment may be medical or surgical and includes nonsteroidal anti-inflammatory drugs, gestagen, dienogest, combination estrogen/progestin contraceptives, progestin-only contraceptives. Other treatments include gonadotropin-releasing hormone analogues, danazol and letrozole drugs and  levonorgestrel-releasing intrauterine system (Mirena). Laparoscopy is used to confirm the diagnosis and to treat many cases such as cystectomy for ovarian endometrioma and electric diathermy coagulation for endometriosis implants and adhesolysis for pelvic adhesions. Hysterectomy and BSO for severe cases not desiring fertility.

Prof. Alaa Mosbah

2019