Endometriosis remains an enigmatic, often debilitating disease affecting
reproductive age women. Endometriosis is defined by the presence of endometrial
glands and stroma outside of the normal intrauterine location associated with
evidence of hemorrhage. This aberrantly located endometrial tissue is under the
influence of ovarian steroids, and one sees a similar response as with normally
located endometrium. Because of their responsiveness to ovarian steroids these
ectopic glands and stroma undergo cycles of proliferation and bleeding on a monthly
basis.
Endometriosis can present with pain, infertility, pelvic masses and some
unusual symptoms such as catamenial epistaxis or hematothorax. The etiology of
endometriosis remains a puzzle with a number of theories to explain it. These
include theories of retrograde menstruation, coelomic metaplasia, venous or lymphatic
dissemination or local implantation.
In the past endometriosis was thought to be a disease of the older reproductive
years, but recently it has been discovered to occur at any time in the reproductive
life of an individual. This knowledge has led to earlier diagnosis and treatment
of this disease. Hopefully this earlier treatment will result in reduced long
term morbidity and complications resulting from endometriosis.
The diagnosis of endometriosis still relies on surgical visualization
and biopsy of lesions with pathologic confirmation of endometrial glands and
stroma outside of the uterus. Typical endometriotic lesions include powder-burn
spots and chocolate cysts (endometriomas) in the ovary. Recent discoveries have
demonstrated glands and stroma in atypical lesions such as clear or pink vesicles.
At the time of surgery it is important to classify the degree of endometriosis
which is dependant on the number of endometriotic lesions and pelvic adhesions.
The American Society of Reproductive Medicine (formerly the American Fertility
Society) has developed a classification system for endometriosis based on the
quantity of endometriosis as well as the quantity and severity of pelvic adhesions.
According to this classification scheme endometriosis can be classified as minimal,
mild, moderate and extensive.
The treatment of endometriosis can be divided into conservative techniques
for those who wish to maintain their fertility and radical for those who have
completed childbearing. Conservative techniques can be further divided into medical
and surgical therapies. Medical therapies function by reducing the cyclic fluctuation
of estrogen and progesterone which is normally seen in the menstrual cycle. The
major medical therapies include oral contraceptive pills either used in the regular
fashion or in a continuous fashion, progestational agents like depo-provera and
gonadotropin releasing hormone agonists. Previously danocrine was popular in
the treatment of endometriosis but has decreased in use due to its number of
androgenic side-effects. New medications which are being tested in the treatment
of endometriosis include progesterone antagonists and aromatase inhibitors. All
of these medical agents have been effective in the treatment of endometriosis.
One draw-back of these medications is that they disrupt normal ovarian steroidogenesis
which disturbs fertility while on the agents. Hence medical therapy tends to
delay fertility until after the patient completes the medical regimen. Current
research will hopefully identify treatments for endometriosis that will enhance
fertility while the patient is on the medication.
Surgical treatment of endometriosis is divided into conservative and radical
methods. Conservative surgery requires removal or destruction of endometriosis
and adhesions while maintaining the reproductive organs. In patients with endometriosis
conservative surgery has been beneficial in improving pregnancy rates and reducing
other symptoms. The disadvantage of conservative surgery is the real possibility
that the endometriosis can return and cause a relapse of symptoms. Radical surgery
involves removing the uterus, fallopian tubes and ovaries as well as any areas
of endometriosis and adhesions which is the definitive treatment for endometriosis.
Current research is exploring less invasive methods of diagnosis of endometriosis
such as blood tests. New research will also hopefully lead to more effective
therapies in young women with this often debilitating disease.
