Endometriosis
Definition: A condition in which tissue that resembles the lining of the uterus
(endometrium) is found outside the uterus. While the most common locations for
the lesions are behind the uterus (cul-de-sac), on the ovaries, or on the bladder
surface, lesions have also been found in the bowel, appendix, c-section scars,
lungs, and even the eye.
Incidence: In the general population, 7-10% of women have endometriosis. Among
infertile women, 20-50% have this condition. The incidence of endometriosis has
not been increasing. This condition can occur in any woman regardless of race.
First-degree relatives of women with endometriosis have 10-fold increased chance
of developing the condition.
Causes: Cells from the cavity of the uterus commonly are found in the abdominal
cavity during menstruation (retrograde menstruation). In some women, perhaps
because of inability of the immune system to reject such cells, they will implant
and grow. Other theories of endometriosis include change of normal cells inside
the abdomen to endometrial cells under unusual stimulation, and spread of cells
from inside the uterus through blood vessels to distant areas.
Signs and Symptoms: Many patients with endometriosis have no symptoms. The severity
of symptoms does not correlate with the severity of endometriosis. Painful periods
(dysmenorrhea), painful intercourse (dyspareunia), infertility, and irregular
periods are the most common symptoms. Tenderness during a pelvic examination
and the presence of nodules or cysts are typical signs though not very common
overall.
Diagnosis: Direct visualization of the condition confirmed by biopsy (if the
surgeon is uncertain about the lesions) is the standard for diagnosis of endometriosis.
This is usually done by laparoscopy as an outpatient. Physical examination and
history are very unreliable and should not be used to establish the diagnosis.
Imaging procedures such as ultrasound or MRI may be suggestive but not diagnostic.
The severity of endometriosis is classified in 4 stages (minimal, mild, moderate,
severe) based on visual criteria at surgery that take into account the size,
depth and location of lesions, as well as accompanying scar tissue.
Treatment: Options include no treatment, medical treatment, or surgical treatment.
No treatment is an appropriate option when endometriosis was diagnosed already
and/or previously treated, and the patient is asymptomatic. Medical treatment
includes birth control pills, progestin (e.g. norethindrone), danazol (rarely
used due to side effects), or GnRH-agonists (e.g. Depo-Lupron). Surgical options
include laparoscopic treatment (by laser or non-laser instruments) as an outpatient;
by laparotomy (larger abdominal incision, usually requiring a short hospitalization-
an uncommon practice nowadays); or a hysterectomy, with or without removal of
ovaries. Treatment must take into account the patient's wishes for future fertility;
the severity of her symptoms and the resulting disability from symptoms; previous
treatments and treatment failures; and side effects and tolerance of medications.
FIRST DO NO HARM should be the motto for the doctor treating endometriosis and
also what the patient should keep in mind when considering treatment options.
Endometriosis and Infertility:
Infertility patients have an increased prevalence of endometriosis. Patients
with endometriosis are more likely to be infertile. The greater the extent of
endometriosis, the lesser the likelihood of pregnancy. Medical or surgical treatment
of endometriosis often improves fertility. How does endometriosis contribute
to infertility? In cases of significant amount of endometriosis, scar tissue
involving the tubes or ovaries may interfere with the normal mechanism of egg
capture by the fallopian tubes following ovulation. Another possible mechanism
contributing to infertility is the various inflammatory substances released in
response to endometriosis lesions that may interfere with ovulation and sperm
function.
Surgical treatment of endometriosis, now mostly accomplished by outpatient laparoscopy,
may generally improve fertility by 25%. Treatment of low grades of endometriosis
(minimal or mild) by surgery results in only modest amount of increase in fertility.
Nevertheless, if laparoscopy is performed for diagnostic purposes, it is advisable
to treat endometriosis even if it is limited. In vitro fertilization (IVF) should
be considered for infertile patients with significant amounts of endometriosis
(moderate or severe). While severe endometriosis may be associated with some
reduction in egg quality, especially if present on the ovaries (endometriomas),
IVF still offers greater chance of pregnancy to patients with severe disease
compared with other infertility treatments. Care must be taken when surgically
treating ovarian endometriosis (endometriomas), since overly aggressive treatment
may result in reduction in blood supply to the ovary and reduction in ovarian
response.
©Copyright Eli Reshef MD
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